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A TREATISE 



ON THE 



MEDICAL AND SURGICAL DISEASES 



INFANCY AND CHILDHOOD 



J. LEWIS SMITH, M.D., 

CLINICAL PROFESSOR OF DISEASES OF CHILDREN, BELLEVUE HOSPITAL MEDICAL COLLEGE J PHYSI- 
CIAN TO CHARITY HOSPITAL; PHYSICIAN TO THE N. Y. FOUNDLING ASYLUM; PHYSICIAN TO THE 
N. Y. INFANT ASYLUM: CONSULTING PHYSICIAN TO THE N. Y. CITY HOSPITAL; CONSULTING 
PHYSICIAN TO THE FRENCH HOSPITAL; CONSULTING PHY'SICIAN TO THE DEPARTMENT 
OF CHILDREN'S DISEASES, BUREAU FOR THE RELIEF OF THE OUT-DOOR POOR, 
BELLEVUE; CONSULTING PHYSICIAN TO THE NURSERY AND CHILD'S 
HOSPITAL, COUNTRY BRANCH; CONSULTING PHYSICIAN TO 
THE INFANT'S HOSPITAL, RANDALL'S ISLAND. 



EIGHTH EDITION, THOROUGHLY REVISED AND GREATLY ENLARGED. 



WITH TWO HUNDRED AND SEVENTY-THREE ILLUSTRATIONS 
AND FOUR COLORED PLATES. 







1% 



LEA BROTHERS & CO., 

NEW YORK AND PHILADELPHIA. 

1896. 



y 




Entered according to Act of Congress in the year 1896, by 

LEA BROTHERS & CO., 

in the Office of the Librarian of Congress, at Washington. All rights reserved. 



WESTCOTT &. THOMSON. PRESS OF 

ELECTROTYPERS, PHILADA. WILLIAM J. DORNAN, PHILADA. 



PREFACE. 



Such advances have recently been made in our knowledge of the 
etiology, pathology, and therapeutic requirements of the diseases of 
children, that in the preparation of the eighth edition the rewriting 
of a large part of the book, with the addition of new chapters, has 
been necessary. Hence an increase in the number of pages was 
unavoidable, although the material has been condensed so far as was 
compatible with clearness of description. 

Fortunately, Prof. Stephen Smith, whose large experience in the 
surgical wards of New York hospitals renders him eminently fitted 
for the task, has added to the text many pages descriptive of the sur- 
gical diseases of children. His reputation as a surgeon and writer 
is sufficient to give the impress of authority, and the certainty of 
clearness and effectiveness, to whatever emanates from his pen. 

The dedication to Dr. Frederic M. Warner becomes the more ap- 
propriate in view of his lamented and untimely death. His large 
clinical experience, careful and accurate study of symptoms, and judi- 
cious selection of remedies especially fitted him for the preparation of 
the chapters assigned to him, which he was unable to finish. The 
proofs of what he had written arrived as he was passing into the 
fatal coma of typhoid. 

The author gratefully acknowledges the assistance rendered by Dr. 
Joseph O. Dwyer, physician to St. Vincent's Hospital and the New 
York Foundling Asylum, in preparing the Section on Intubation ; 
also the assistance of Dr. A. R. Robinson, Professor of Dermatology 
in the New York Polyclinic, whose illustrations, generously loaned, 
and his contributions to the text, have greatly increased the value of 
the Section on Skin Diseases. 

J. LEWIS SMITH. M. D. 

64 West 56th Street, New York City. 



CONTENTS. 



PART I. 
INFANCY AND CHILDHOOD. 



CHAPTEE I. 

PAGE 

Their Anatomy and Physiology 17 

CHAPTER II. 
Care of the Mother in Pregnancy 19 

CHAPTER III. 

Mortality of Early Life : Its Cause and Prevention 22 

CHAPTER IV. 

Weight, Growth, Temperature, Pulse, Respiration 26 

Wet-nursing: its Advantages and Hindrances; Physical Conditions rendering it 
Improper — Colostrum — Human Milk — Modification of Milk in Consequence 
of the Diet — Modification of Milk from its Retention in the Breast — Modifica- 
tion of Milk by Age and by Mental Impressions — Modification of Milk by the 
Cataraenial Function, Pregnancy, and other Causes — Effect of Medicine on the 
Mother's Milk — Differences in Women as regards Quantity and Quality of 
Milk — Rules in regard to Lactation. 

CHAPTER V. 
Selection of a Wet-nurse 42 

CHAPTER VI. 
Course of Wet-nursing— Weaning 45. 

CHAPTER VII. 

Quantity of Food Required in Infancy and Childhood 47 

CHAPTER VIII. 
Artificial Feeding 53 

CHAPTER IX. 
Bathing, Clothing, Sleep, Exercise 65 

V 



vi CONTENTS. 

CHAPTER X. 

PAGE 

Diagnosis of Infantile Feeding 70 

General Observations — Features; External Appearance of the Head, Trunk, 
and Limbs in Disease — Attitude — Movements — The Voice — Respiratory Sys- 
tem — Circulatory System — Animal Heat — Digestive System — Nervous System. 

CHAPTER XL 
Therapeutics 80 



PART II. 
DISEASES OF THE NEWLY-BORN. 



CHAPTER I. 

Malformations. 82 

Acrania — Meningocele, Encephalocele, Hydrencephalocele — Spina Bifida — 
Congenital Abnormalities in the Circulatory System — Cyanosis — Caput Succe- 
daneum — Cephalhematoma. 

CHAPTER II. 

Local Diseases 101 

Hematoma of the Sterno-cleido-mastoid Muscle — Mastitis — Conjunctivitis — 
Ophthalmia Neonatorum — Umbilical Vegetations — L T mbilical Hemorrhage — 
Icterus — Septicemia of the New-born — Thrush. 

CHAPTER III. 

Diarrhcea, Constipation, and Tetanus of the New-born 128 

Diarrhoea of the Newly-born — Constipation of the Newly-born — Tetanus Neo- 
natorum — Sclerema Neonatorum — (Edema Neonatorum — Pemphigus Neona- 
torum — Osteogenesis Imperfecta. 



PAET III. 
CONSTITUTIONAL DISEASES. 



SECTION I. 
DIATHETIC DISEASES. 



CHAPTER I. 

Rachitis 156 



CONTENTS. vii 

CHAPTEK II. 

PAGE 

Scrofula 186 

CHAPTER III. 
Tuberculosis 202 

CHAPTER IV. 
Syphilis 230 

SECTION II. 
ERUPTIVE FEVERS. 

CHAPTER I. 
Measles 242 

CHAPTER II. 
Scarlet Fever 250 

CHAPTER III. 

ROTHELN 298 

CHAPTER IV. 
Variola — Varioloid 306 

CHAPTER V. 
Vaccinia 316 

CHAPTER VI. 
Varicella 326 

CHAPTER VII. 
Diphtheria 32S 

CHAPTER VIII. 
Pertussis 381 

CHAPTER IX. 
Mumps 395 



SECTION III. 
OTHER GENERAL DISEASES. 

CHAPTER I. 

Intermittent Fever 399 



viii CONTEXTS. 

CHAPTEE II. 

PAGE 

Remittent Fever 405 

CHAPTER III. 
Typhoid Fever 407 

CHAPTEE IV. 
Cerebrospinal Fever 421 

CHAPTEE V. 
Acute Eheumatism 455 

CHAPTEE VI. 
Erysipelas 463 



SECTION IV. 

MALFORMATIONS AND DEFORMITIES. 



CHAPTER I. 

The Digestive Organs 476 

Lips and Palate — The Tongue — The Eectum — The Anus. 

CHAPTER II. 
The Urinary Bladder 489 

CHAPTEE III. 

The Extremities 490 

The Upper Extremities — The Knee — The Leg — The Feet. 



PAET IV. 

SECTION I. 
DISEASES OF THE BLOOD. 

CHAPTER I. 
Mel^na Neonatorum . 504 



CONTENTS. ix 

CHAPTER II. 

PAGE 

Simple or Secondary Anemia 507 

CHAPTER III. 
Primary Anemia 511 

Leukaemia (Leucoeythaeruia) — Pseudoleukemia (Lymphatic Anaemia; Hodg- 
kin's Disease) — Splenic Anaemia — Pernicious Anaemia (Anaemic Fever, Idio- 
pathic Anaemia) — Haemophilia — Purpura — Scorbutus (Scurvy). 



PAET V. 
LOCAL DISEASES. 



SECTION I. 
INJURIES AND DISEASES OF THE OSSEOUS SYSTEM. 



CHAPTER I. 

Caries of the Vertebra 519 

CHAPTER II. 
Lateral Curvature of the Spine 525 

CHAPTER III. 

Injuries of Bones 530 

Injuries of the Skull — Injuries of Long Bones. 

CHAPTER IV. 
Diseases of Bone 538 

CHAPTER V. 

Diseases of the Joints 552 

The Shoulder-joint— The Elbow-joint— The Wrist -joint —The Hip-joint— The 
Knee-joint — The Ankle-joint — The Tarsus— The Foot. 



SECTION II. 
DISEASES OF THE CEREBRO-SPINAL SYSTEM. 



CHAPTER 1. 
Congestion of the Brain 578 



x CONTEXTS. 

CHAPTEK II. 

PAGE 

Intracranial Hemorrhage (Meningeal Hemorrhage, Cerebral Hem- 
orrhage) , 581 

CHAPTEK III. 
Congenital Hydrocephalus 589 

CHAPTEK IV. 

Acquired Hydrocephalus 595 

CHAPTEK V. 

Meningitis (Tubercular and Non-Tubercular) 596 

CHAPTER VI. 
Spurious Hydrocephalus 611 

CHAPTER VII. 
Eclampsia 614 

CHAPTER VIII. 
Epilepsy 622 

CHAPTER IX. 

Internal Convulsions (Spasm of the Glottis; Laryngismus Stridulus) 634 

CHAPTER X. 

Tetany 640 

CHAPTER XI. 
Chorea 650 

CHAPTER XII. 
Paralysis 664 

CHAPTER XIII. 

Poliomyelitis Acute Anterior .... - 664 

CHAPTER XIV. 

Facial Paralysis 671 

CHAPTER XV. 

Pseudo-Hypertrophic Paralysis 672 

CHAPTER XVI. 

Diseases of the Spinal Cord and its Coverings 676 

CHAPTER XVII. 

Congestion of the Spinal Cord and its Membranes 677 



CONTENTS. xi 

SECTION III. 
DISEASES OF THE DIGESTIVE APPARATUS. 



CHAPTER I. 

PAGE 

Simple Stomatitis, Ulcerous Stomatitis, Follicular Stomatitis - . . . 680 

CHAPTER II. 
Gangrene of the Mouth 684 

Efflorescence, Furring, and Eruptions upon the Tongue. 

CHAPTER III. 

Dentition 691 

Ranula — Alveola — Tonsil. 

CHAPTER IV. 
Catarrhal Pharyngitis, Peripharyngeal Abscess, (Esophagitis .... 701 

CHAPTER V. 

Indigestion, Congestion of Stomach, Gastritis, Follicular Gastritis, 

Diphtheritic Gastritis 714 

CHAPTER VI. 
Gastro-intestinal Bacteria 723 

CHAPTER VII. 
Simple Diarrhcea 726 

CHAPTER VIII. 

Intestinal Catarrh of Infancy (Entero-Colitis) 730 

Cholera Infantum, or Choleriform Diarrhoea. 

CHAPTER IX. 

Enteritis and Colitis in Childhood 752 

CHAPTER X. 

Constipation 754 

CHAPTER XI. 
Intestinal Worms 765 

CHAPTER XII. 

Intussusception 779 

CHAPTER XIII. 

Appendicitis and Peritonitis 799 



xii CONTENTS. 

CHAPTER XIV. 

PAGE 

Hernia of the Abdomen 809 

SECTION IV. 
DISEASES OF THE RESPIRATORY SYSTEM. 



CHAPTER I. 
Coryza 818 

CHAPTER II. 

Laryngitis • 820 

CHAPTER III. 
Diseases of the Larynx 828 

CHAPTER IV. 
Pseudo-membranous Croup (True Croup) 831 

CHAPTER V. 
Intubation 839 

CHAPTER VI. 
Tracheotomy 848 

CHAPTER VII. 
Bronchitis 851 

CHAPTER VIII. 
Atelectasis 861 

CHAPTER IX. 
Pneumonia 864 

CHAPTER X. 

Pleurisy 876 



SECTION V. 
DISEASES OF THE CIRCULATORY SYSTEM. 



CHAPTER I. 

Diseases of the Heart 912 

Functional Disorders. 

CHAPTER II. 
Pericarditis 913 



CONTENTS. xm 

CHAPTEE III. 

PAGE 

Myocarditis 916 

CHAPTEE IV. 
Endocarditis 917 

CHAPTEE V. 
Ulcerative Endocarditis 919 

CHAPTEE VI. 
Chronic Endocarditis 920 

CHAPTEE VII. 
Diseases of the Vessels 923 



SECTION VI. 

DISEASES OF THE GENITO-UEINAEY OEGANS. 

Calculi ; Dysuria ; Cryptorchia — Vulvitis — Preputial Dilatation — The Kidneys — 
The Urinary Bladder— The Urethra— The Penis— The Scrotum— The Testicles 927 



SECTION VII. 

DISEASES OF THE SKIN. 

Erythema — Urticaria — Prurigo — Eczema — The Pathogenic Effects of Microbes — 
Parasites of the Skin 949 



THE 



DISEASES OF CHILDREN. 



PART I. 

INFANCY AND CHILDHOOD. 



CHAPTER I. 

THEIR ANATOMY AND PHYSIOLOGY. 

Infancy and childhood are, in certain respects, the most important and 
interesting periods of life. To the physiologist they are especially interest- 
ing, because they are the periods of development and of greatest functional 
activity ; to the pathologist, because in them many diseases occur which are 
rarely or never observed in the other periods, or which present in these periods 
peculiar features ; to the physician and vital statistician, because in them 
the greatest amount of sickness and the largest number of deaths occur. 

Infancy extends from birth to the age of two and a half years, or 
till the completion of the first dentition. In infancy the organs are delicately 
organized, containing a large proportion of water, and hence are easily 
injured. In this period the brain is rapidly developed — more so than any 
other organ ; animal matter predominates in the bones ; the arteries are rel- 
atively large, the muscles small ; the superficial veins are small. Fat is 
absent from the interior of the body, but abundant, in well-nourished infants, 
underneath the integument. The skin is delicate, and its temperature not 
much below that of the blood. At birth it has a reddish hue and is covered 
with soft, fine hairs (lanugo). The reddish hue gradually fades into the 
healthy tint of infancy, and the hairs fall out. In the first two months the 
sweat-glands have little functional activity, sensible perspiration being quite 
rare. Subsequently, perspiration is freer, and in certain diseased states 
(rachitis, etc.) is abundant. The sebaceous glands in the first half of infancy 
are active, particularly upon the scalp, producing often a pale-yellow incrusta- 
tion consisting of sebaceous matter and epidermic cells. 

The secretions from the mucous surfaces commence at an early period. 
At birth the surface of the digestive tube is covered with more or less 
mucus, often in considerable quantity. The meconium is not considered, 
as formerly, to be a product of intestinal secretion. It consists of flat 
epithelial cells, fine hairs, oil-globules, crystals of cholesterin, and brownish 
or yellowish masses of coloring matter, probably from the liver. It is sup- 
2 17 



18 INFANCY AND CHILDHOOD. 

posed that, with the exception of the coloring matter, the meconium is 
derived mainly from the amniotic fluid which the foetus has swallowed. 

The most wonderful change occurring in the system at birth, through 
the exigencies of the new life, is that in the circulation. The flow of blood 
being interrupted, thrombi form in the umbilical vein and arteries, and in 
the ductus arteriosus and ductus venosus, and these vessels gradually atro- 
phy, becoming finally shrivelled but permanent cords. I have many times 
at autopsies removed the plug from the ductus arteriosus when death had 
occurred as late as the third week. The foramen ovale closes slowly. I 
have ordinarily found it open till near the end of the first half year, but 
the valve covers fully the aperture, so that there is no detriment to the cir- 
culation. Both the pulse and respiration are more frequent during infancy 
than childhood, and are more accelerated by moral and physical causes. 

The stomach has a smaller relative size and emesis is more readily caused 
than in the adult. The liver is large, occupying at birth nearly half of the 
abdominal cavity, but its proportionate size becomes less in subsequent 
months, from a less rapid growth. The appetite is good and digestion 
active, so that hunger, when appeased, soon returns. The thymus gland, 
at birth about the size of an unexpanded lung, slowly atrophies, but it does 
not totally disappear till after infancy. 

The kidneys, distinctly lobulated at birth, gradually change their form, 
so as to present in the last part of infancy nearly the shape of the organ in 
the adult. The renal secretion commences early, even before birth. The 
kidneys seldom undergo degenerative changes as in the adult, but they are 
liable to congestions and inflammations. During the first month, and espe- 
cially the first fortnight, crystals of uric acid and the urates are often found 
in the urine in a state of apparent health, causing more or less fretfulness in 
their elimination, staining the diaper, and not infrequently being arrested in 
the tubules of the pyramids, where they can be seen as pink-colored spots or 
lines (uric-acid infarction). These deposits of uric acid and the urates may 
even occur in the foetus, producing obstruction and inflammation of the renal 
tubes. Congenital cystic degeneration of the kidneys is, in the opinion of 
Virchow, due to them. In early infancy the senses are imperfectly devel- 
oped, the eyes being attracted only by bright objects, and the sense of hear- 
ing affected only by loud noises. Sleep is the normal state in the first weeks 
of life : as the age of the infant increases, less and less sleep is required ; but 
the oldest infants need more than children and several hours more than adults. 

The new-born infant is apparently destitute of mental faculties. It seeks 
the breast by instinct, and it exhibits no perception or reflection. The loud 
cries with which it commences its existence are not from anger or suffering ; 
they appear to be normal, like the act of nursing, and providentially designed 
to expand the lungs. It is not till the close or near the close of the first 
month that the gray substance of the brain begins to appear — the probable 
seat of the mind and the source of all mental phenomena. Perception 
and curiosity are early manifested. The infant, as Edmund Burke has 
remarked, is constantly seeking new objects for its amusement, rejecting old 
playthings for such as possess more novelty. Reflection, a higher faculty 
of the mind, appears at a later period. The mind and the bodily organs in 
infancy are, in a high' degree, impressionable. Anger is excited by trivial 
causes, but is easily appeased, and the various functions in the system are 
disturbed by agencies which in youth or manhood would have no appreciable 
effect. 

Childhood extends from infancy to the age of fifteen years or puberty. 
It is a period of great physical activity and of rapid growth. The functions 
of the various organs are performed with more moderation than in infancy, 



CARE OF THE MOTHER IN PREGNANCY. 19 

and are less frequently deranged. The volume of the brain continues to 
increase rapidly, and it becomes firmer than in infancy. It is estimated that 
by the seventh year the weight of this organ has doubled. The mind now 
exerts a controlling influence over the actions of the individual. The digestive 
organs have changed, so that solid food is required. Most of the grandular 
organs are less active than in the greater part of infancy. The pulse and 
respiration gradually become less frequent as the child advances in age. 



CHAPTER II. 

CAKE OF THE MOTHER IN PREGNANCY. 

The frequency of miscarriages and stillbirths, and the large number of 
ill-formed and puny infants born to a precarious and short existence, render 
imperative, on the part of the mother, a strict observance of the laws of 
health, and an avoidance of all exciting or perturbating influences during 
the time when the foetus is being developed. The diet should be plain and 
easily digested, but nutritious. There is often a craving in pregnancy for 
unusual articles of food. These may sometimes be allowed within certain 
limits, provided that they are such as do not derange the stomach. Meats 
and animal broths, together with vegetables and farinaceous food, should con- 
stitute the ordinary diet and should be taken at regular intervals. 

Daily exercise, never violent, but moderate and gentle, is requisite. No 
exercise is better, none safer and more likely to contribute to cheerfulness 
and healthy functional activity of the organs, than the ordinary household 
duties. Lifting heavy weights or work which, like washing and ironing, 
causes great and continued action of the abdominal muscles, should be 
avoided. Such exercise is highly injurious, and it may produce premature 
labor. Exercise in the open air on foot or by an easy conveyance conduces 
to the health of the mother and the growth and development of the foetus. 
On the other hand, rapid riding over rough roads is one of the most dangerous 
modes of exercise. It has been known to destroy the foetus, which up to 
that time had been apparently vigorous. When such a result occurs there 
is probably more or less detachment of the placenta. 

It being a matter of the utmost importance that the health of the mother 
should continue good during gestation, any disease which she may have in 
this period, and which affects her nutrition or the character of her blood, 
should be promptly cured if practicable, and with the least possible reduction 
of the vital powers. Intermittent fever, occurring during gestation, should 
never be allowed to continue. It seriously retards foetal development and 
may produce miscarriage. Unless it be controlled by proper measures, the 
offspring, though born at term, is puny and emaciated. Syphilis in the preg- 
nant woman also requires treatment. This disease, readily transmitted from 
the mother to the foetus through the ovum or the uterine circulation, may be 
eradicated by antisyphilitic treatment of the mother, or at least so modified 
that the infant is born vigorous and healthy. 

The pregnant woman should avoid all causes of undue mental excite- 
ment. This is almost as necessary as the avoidance of great physical exer- 
tion. There is, during pregnancy, unusual susceptibility to mental impres- 
sions, and this should be borne in mind not only by the woman herself, but 
by those who associate with her. 



20 INFANCY AND CHILDHOOD. 

Strong emotions, whether of joy, sorrow, or anger, affect primarily the 
nervous system, but indirectly most of the organs of the body. Observa- 
tions have long established the fact that such emotions influence the state 
and functions not only of the digestive and glandular, but also of the mus- 
cular, organs, as the heart and uterus. Physicians are familiar with cases 
in which vivid mental impressions produced uterine contractions, and even 
miscarriage, or have disturbed the catamenial function. Therefore, the asso- 
ciations and cares of pregnant women should be such as conduce to cheerful- 
ness and equanimity. 

It is the popular belief and the belief of many physicians that vivid 
mental impressions sometimes have a direct effect on the development of 
the foetus. Many cases are on record in which infants were born with marks 
or deformities corresponding in character with objects which had been seen 
and had made a strong impression on the maternal mind at some period of 
gestation. Whether the mind of the mother exerts a controlling influence 
on the form and color of the foetus is a subject of great interest to the psy- 
chologist as well as the physiologist and physician, since it involves no less a 
question than the power and scope of the human mind. Violent emotions, 
it is admitted, may affect directly most of the important organs in the system. 
They may derange the liver, causing jaundice, accelerate, or for a moment 
suspend, the heart's action, stimulate the kidneys, causing diuresis, or even 
the intestinal follicles, causing watery evacuations. But with all these organs 
the brain is connected by nerves which anatomy reveals. On the other hand, 
the mother and foetus have a distinct existence as regards their nervous sys- 
tems, and even their blood. Still, the multitude of facts which have accumu- 
lated justify the belief that deformity or other abnormal development of the 
foetus is, at times, due to the emotions of the mother. Some of the cases 
related by Dr. Whitehead in his work on hereditary diseases are very strik- 
ing and difficult to explain on the ground of coincidence. I have met the 
following cases : An Irish woman of strong emotions and superstitions was 
passing along a street in the first months of her gestation, when she was 
accosted by a beggar, who raised her hand, destitute of thumb and fingers, 
and in " God's name " asked for alms. The woman passed on, but reflecting 
in whose name money was asked, felt that she had committed a great sin in 
refusing assistance. She returned to the place where she had met the beggar, 
and on different days, but never afterward saw her. Harassed by the thought 
of her imaginary sin, so that for weeks, according to her statement, she was 
made wretched by it, she approached her confinement. A female infant was 
born, otherwise perfect, but lacking the fingers and thumb of one hand. The 
deformed limb was on the same side as, and it seemed to the mother to 
resemble precisely, that of the beggar. In another case which I met a very 
similar malformation was attributed by the mother of the child to an accident 
occurring to a near relative which necessitated amputation during the time of 
her gestation. I examined both of these children with defective limbs, and 
have no doubt of the truthfulness of the parents. In May, 1868, I removed 
a supernumerary thumb from an infant whose mother, a baker's wife, gave 
me the following history : No one of the family and no ancestor, to her 
knowledge, presented this deformity. In the early months of her gestation 
she sold bread from the counter, and nearly every day a child with double 
thumb came in for a penny roll, presenting the penny between the thumb and 
the finger. After the third month she left the bakery, but the malformation 
was so impressed upon her mind that she was not surprised to see it repro- 

duced in her infant. Mrs. S , West Fiftieth street. New York, when in the 

Beventh week of gestation, saw a child with fingers united, so that they resem- 
bled the palm of the hand extended. She was much excited at the appear- 



CARE OF THE MOTHER IN PREGNANCY. 21 

anee. and clutclied the window-sill with such force as to cause abrasion of 
the fingers. The malformation of the child made a deep and lasting impres- 
sion on her mind, and her child, born at term, had the index, middle, and ring 
fingers of the left hand webbed and ending with the first phalanges, while the 

little finger was normal. Mrs. D , Eighth avenue, New York, seven 

months before the birth of her child, when visiting at a distance, accident- 
ally broke the plate of a full set of upper teeth. The line of fracture was 
antero-posterior and through the centre of the plate. Being away from home, 
she was much annoyed by the accident, and retained the fragments of the 
plate in situ by pressure with the tongue. As she could not open her mouth 
without the plate falling out, except it was retained by pressure with the tongue, 
her mind was dwelling almost constantly on the accident during the few days 
of her visit. Her boy, born seven months subsequently, had a hare-lip and 
cleft palate. The mother stated that the deficiency in the lip and palate cor- 
responded precisely to the location of the fracture in the plate. Dr. G-reenley 
relates five similar cases in which infants at birth presented marks or arrested 
development corresponding in appearance with objects which produced strong 
mental impressions in the mothers {Aimer. Prac. and News, Oct. 29, 1887). 

Dr. William A. Hammond of Washington, in an interesting paper on the 
"Influence of the Maternal Mind," etc. {Quarterly Journal of Physiological 
Medicine, January, 1868), says: " The chances of these instances, and others 
which I have mentioned, being due to coincidence are infinitesimally small, 
and though I am careful not to reason upon the principle of post hoc, ergo 
propter hoc, I cannot, nor do I think any other person can, no matter how 
logical may be his mind, reason fairly against the connection of cause and 
effect in such cases. The correctness of the facts can only be questioned ; 
if these be accepted, the probabilities are thousands of millions to one that 
the relation between the phenomena is direct." Professor Dalton also says 
{Human Physiology} : " There is now little room for doubt that various deform- 
ities and deficiencies of the foetus, conformably to the popular belief, do really 
originate in certain cases from nervous impressions, such as disgust, fear, or 
anger, experienced by the mother." The observations on which this belief is 
based relate both to man and the lower animals. A very strong argument in 
its support is, as Professor Hammond remarks, the popular opinion, which 
dates back to the time of Jacob (Genesis xxx.). An almost universal senti- 
ment, running through centuries, is rarely wholly fallacious. It has some 
truth for its foundation, especially when, as in this instance the subject is 
one of observation. 

If maternal emotions affect the development of the exterior of the foetus, 
as observations show and physiologists admit, the presumption is strong that 
they may affect also the proper development and adjustment of the parts of 
the brain, an organ so complex and delicate, and may therefore give rise to 
idiocy. Dr. Seguin {Idiocy and its Treatment, etc., New York, 1866) thus 
remarks on this point : " Impressions will sometimes reach the foetus in its 

recess, cut off its legs or arms or inflict large flesh wounds before birth 

from which we surmise that idiocy holds unknown though certain relations 
to maternal impressions as modifications to placental nutrition." 

In volume i. of the Cyclopsedia of Disease* of Children (Philadelphia, 
1889) Dr. W. C. Dabney has published the statistics of 90 cases showing 
that both mental and bodily defects in the infant sometimes result from 
vivid mental impressions in the mother during the early months oi" her ges- 
tation. These cases are mostly collated from recent medical literature, and 
many of them are striking instances showing the effect of maternal impres- 
sions in causing malformations in the foetus, not only in the human race, but 
also in quadrupeds. Dr. Dabney also relates the remarkable statement of 



22 INFANCY AXD CHILDHOOD. 

Baron Larrey, that 92 enceinte women who had experienced extreme mental 
and physical suffering at the siege of Landau in 1793 brought forth infants 
with the following result : born dead, 16 ; born alive, but dying in ten months, 
33 ; born idiotic, 8 ; born with bones ununited or in a fragmentary state, 2. 

It is an interesting fact that abnormalities of structure occurring from 
whatever cause are sometimes propagated to descendants. Dr. Carpenter 
and others relate instances among the lower animals, and similar instances 
of transmission have now and then been observed in the human race. Thus, 
in the issue of Nature for March 7, 1878, it is stated on the authority of M. 
Lenglen, a physician of Arras, that a certain M. Gamelon in the last century 
had two thumbs on each hand and two great toes on each foot : this peculi- 
arity did not appear in the son, but it reappeared in the three succeeding 
generations, so that some of the great-great-grandchildren possessed it in as 
marked a degree as their ancestors. 

In view of such important facts the duty of the pregnant woman is ren- 
dered the more imperative to avoid the presence of disagreeable and unsightly 
objects, as well as all causes of excitement, and to remove, as soon as possible, 
vivid and unpleasant impressions by quiet diversion of the mind. 



CHAPTER III. 

MORTALITY OF EARLY LIFE: ITS CAUSES AND PREVENTION. 

No fact is better known in the profession than that the first years of life 
constitute the period of greatest mortality. 

In England, where there is an accurate registration of births and deaths, 
statistics show fifteen deaths in every hundred infants in the first year of life, 
and between four and five deaths in the first month. Statistics on the Con- 
tinent correspond with those in England as regards the periods of greatest 
mortality. Quetelet says :...." There die during the first month after birth 
four times as many children as during the second month after birth, and 
almost as many as during the entirety of the two years that follow the first 
year, although even then the mortality is high. The tables of mortality 
prove, in fact, that one-tenth of children born die before the first month has 
been completed." 

In this country, in consequence of deficient registration of births, the per- 
centage of deaths to births cannot be accurately ascertained. In New York 
City 53 per cent, of the total number of deaths occur under the age of five 
years, and 26 per cent, under the age of one year. According to the census 
of 1865, there were in New York City 95,020 children under the age of five 
years, and during the five years ending with 1865, 49,000 children five years 
old and under had died. Therefore, according to these statistics, more than 
one-third of all the infants born in this city die under the age of five years. 
An error, however, occurs from the fact that, while the death-statistics were 
complete, it is known that there were more children in the city than were em- 
braced in the census returns. Still, it may, I think, be safely stated that one- 
fifth of the children born in New York City die before the age of five years. 

In less-crowded cities and the rural districts it is known that the percent- 
age of deaths in the first years of life to the total number of deaths is con- 
siderably less than in New York City, but it is nevertheless large. 

As the child advances toward puberty the liability to sickness and death 



MORTALITY OF EARLY LIFE. 23 

gradually diminishes, but even the last years of childhood present a con- 
siderably larger percentage of deaths to the population than does youth or 
manhood. 

The causes of this great mortality of infants and children, and the means 
of diminishing it, deserve careful consideration. 

Some of the causes which conspire to produce it are to a considerable 
extent unavoidable. Such are congenital vices of formation of internal 
organs. Many of the internal malformations necessarily occasion an early 
death. Cases of anencephalus, most cases of congenital hydrocephalus, of 
spina bifida, of cyanosis, are fatal before the close of infancy. These defects 
of formation we cannot detect before birth, and their causes are often obscure. 
Some of them seem to result from inflammation, believed to be, occasionally, 
syphilitic, developed at some period of foetal existence. Other internal mal- 
formations are attributable to perturbating influences operating temporarily 
on the mother during gestation. But in a large proportion of cases we can- 
not assign the cause. Obviously, only partial success attends our efforts as 
regards prevention in these cases, and almost no success as regards the use 
of remedial measures. 

Another obvious cause of the great mortality of early life is natural fee- 
bleness of system, especially in infancy. The younger the patient prior to 
the middle period of life, the sooner are the vital powers exhausted by dis- 
ease. Hence a larger proportion of infants succumb to the same malady 
than children, and a larger proportion of children than adults. This state- 
ment is true of infancy and childhood in general. It is a law in nature, and 
cannot be changed by art. But there are many infants born with hereditary 
disease or a strong predisposition to disease through a fault which is, in a 
degree, curable in the system of one or both parents ; as, for example, the 
syphilitic, scrofulous, or tubercular diathesis. Parents seriously affected by 
such diseases cannot, without corrective treatment, have healthy offspring. 
Their children are among the first to droop and die, either directly from the 
inherited disease or from feebleness of constitution which such disease entails, 
and which renders them an easy prey to other diseases. The duty of the 
physician as regards such parents is obvious. He may, by therapeutic and 
hygienic measures, secure a more healthy progeny, and so far as he can do 
this he aids in diminishing the infantile mortality. He may sometimes, by 
timely measures directed to the infant, establish a better state of health. 

The subject of hereditary disease is one of great interest and importance, 
especially as regards the city population. Inherited affections are less com- 
mon in the country, but in the city they contribute largely to the number of 
deaths in early life. 

Another important cause of the great mortality of children is the fact 
that they are peculiarly liable to certain severe and fatal maladies. I allude 
particularly to the acute communicable diseases, which, as a rule, occur but 
once, and then in childhood. Some of them, as scarlet fever, greatly increase 
the number of deaths. They extend and become epidemic through the inter- 
course of children. We are constantly witnessing in New York the spread 
of the acute contagious diseases, especially of whooping cough, measles, scar- 
let fever, and diphtheria, through the schools. Measures employed, thus far. 
by Boards of Health or other local authorities to prevent the dissemination of 
these and kindred diseases have been but partially successful, except in regard 
to small-pox. In the large public schools especially these maladies are most 
frequently contracted, and from them they radiate over the school districts : 
for if, as is now common, at least in New York City, a child comes to school 
wearing clothes which at home have lain in a room where a brother or sister 
has been sick with diphtheria or scarlet fever, or if he enter the class with a 



24 INFANCY AND CHILDHOOD. 

mild pertussis or measles, certain of his classmates will probably return home 
infected with the virus of the disease. The same remarks are applicable, 
though with less force, to private schools. From both such schools I have 
over and over again witnessed the dissemination not only of the maladies 
mentioned, but also of the milder infectious diseases, as mumps and varicella. 
The Health Board of New York City has recently, by stringent enactments 
regulating the schools, accomplished much in suppressing this source of the 
infectious diseases. 

In hospitals and asylums for children much can be done to prevent the 
occurrence of the infectious diseases by strict surveillance and prompt isola- 
tion of all suspicious cases. Without such care scarcely a year passes in 
which these institutions are not scourged by one or more of these maladies. 
Much has been said of the crowding of families in tenement-houses so com- 
mon in New York and other large cities, by which a large number of children 
are brought under one roof, of the uncleanliness of person and apartment to 
which it leads, and of the insufficient air and space which it allows to each. 
But one of the strongest objections, in my opinion, to the present plan of 
building and crowding tenement-houses is the facility which it affords for the 
spread of the contagious diseases of childhood ; and it is in such houses, as 
shown by statistics, that these maladies are the most frequent and fatal. The 
much-needed enactments or rules in relation to the construction and occu- 
pancy of such houses would, among other salutary effects, greatly diminish 
the death-rate from the infectious maladies. 

Over the most loathsome, and formerly the most fatal, malady of man- 
kind — namely, small-pox — we now have, or can have, complete control by 
statutory enactments enforcing vaccination. It is only by carelessness or 
the lack of sufficiently stringent regulations relating to the matter that small- 
pox is not "stamped out." Again, some of the most fatal inflammatory 
diseases of life occur chiefly in childhood, as croup and capillary bronchitis. 
These and kindred diseases can only be prevented by proper hygienic man- 
agement on the part of families, and measures calculated to educate fam- 
ilies in reference to the management of children cannot fail to diminish the 
number of cases of such inflammations, and, consequently, of the deaths from 
them. 

Another obvious and important cause of the mortality of early life is the 
antihygienic condition or state in which many children live in consequence 
of the poverty or gross negligence of parents. 

Residence in insalubrious localities, personal and domiciliary uncleanliness, 
exposure without proper protection to vicissitudes of weather, are fertile 
causes of sickness and death. Hence one reason for the great infantile 
mortality among the city poor, who live in damp and dark alleys and in 
crowded and filthy tenement-houses, breathing night and day an atmosphere 
loaded with noxious gases. All physicians are aware how the most fatal 
diseases, such as Asiatic cholera, cholera infantum, diphtheria, and scarlet 
fever, seek the quarters of the city poor, and what terrible havoc they make 
there. All are aware, also, what wonderful recoveries result when feeble and 
attenuated infants, gradually sinking with chronic diseases, induced in great 
measure by the foul air, are transferred from such localities to the pure air 
of the country. 

Careless management of young children as regards dress increases greatly 
the liability to local diseases, such as commonly occur from exposure to cold. 
These are inflammatory affections seated chiefly upon the mucous surfaces, 
but sometimes in parenchymatous organs. Adults, aware of the effect of 
sudden change of temperature from warm to cold or of exposure to currents 
of air, protect themselves by additional clothing. Such precautionary meas- 



MORTALITY OF EARLY LIFE. 25 

ures are often lacking in the management of young children, and hence one 
cause of their liability to local affections, both of the respiratory and diges- 
tive organs. 

Eonth, in his excellent treatise on Infant Feeding, says : " Among the 
most pernicious influences to young children, however, we may include cold ; 
the change of temperature from 45° to four or five below zero, as before 
stated, producing an increase of mortality in London alone of three to five 
hundred. As out of 100 deaths, however, from all specified causes, nearly 
24 occur to children under one year, and 36 to children under five, the great 
increase of mortality to children by cold is thus at once made obvious. 
Indeed, it is a household word among us, which takes its origin from the 
Registrar-General's returns, that a very cold week always increases the 
mortality of the very young and the very aged." 

Lastly, a very important cause of mortality in early life is the use of 
improper food. In infants artificial feeding in place of the aliment which 
nature has provided for them, and in children the use of innutritious or indi- 
gestible articles of diet, give rise to diarrhceal maladies, emaciation, and death 
in numerous instances. Sometimes, also, defective alimentation is the cause 
of scrofulous or tuberculous ailments, and sometimes it gives rise to a 
cachexia or feebleness of system which, without engendering any positive 
disease, renders those thus affected less able to support disease induced by 
other causes. A committee, of which Professor Austin Flint, Jr., was chair- 
man, appointed in 1867 to revise the " dietary table of the children's nurseries 
on Randall's Island," states with much truth and force : " Children .... 
are not capable of resisting bad alimentation, either as regards quantity, 
quality, or variety. At that age the demands of the system for nourishment 
are in excess of the waste, the extra quantity being required for growth and 
development. If the proper quantity and variety of food be not provided, 
full development cannot take place, and the children grow up, if they sur- 
vive, into puny men and women, incapable of the ordinary amount of labor 
and liable to diseases of various kinds." 

Improper feeding, like other causes of mortality, is much more injurious, 
much more frequently the cause of death, in the city than in the country. 
Statistics in Europe, as well as on this side of the Atlantic, establish this fact. 
It is in infancy, and especially in the first year, that the use of unwholesome 
food entails the most serious consequences. No artificially-prepared food is 
a good substitute for the mother's milk, and hence artificial feeding of the 
infant, unless under the most favorable circumstances, results disastrously. 
In the country, where salubrious air and sunlight conspire to invigorate the 
system, where a robust constitution is inherited, and where cow's milk, fresh 
and of the best quality, is readily obtained, lactation is not so necessary for 
the well-being of the infant ; but in the city its importance cannot be too 
strongly urged. 

The foundlings of cities afford the most striking and convincing proof of 
the advantages of wet-nursing. In some cities foundlings are wet-nursed T 
while in others they are dry-nursed, and the result is always greatly in favor 
of the former. Thus, on the Continent, in Lyons and Parthenay, where 
foundlings are wet-nursed almost from the time that they are received, the 
deaths are 33.7 and 35 per cent. On the other hand, in Paris, Rheims, and 
Aix, where the foundlings were wholly dry-nursed at the date of the statis- 
tics, their deaths were 50.3, 63.9, and 80 per cent. 

In New York City the foundlings, amounting to several hundred a year, 
were formerly dry-nursed, and, incredible as it may appear, their mortality 
with this mode of alimentation nearly reached 100 per cent. Xow wet-nurses 
are employed for a portion of the foundlings, with a much more favorable 



26 INFANCY AND CHILDHOOD. 

result. Several years ago, before the New York Foundling Asylum existed, 
the foundlings of New York were taken eare of by the pauper women of the 
almshouse, and the medical board of Charity Hospital assigned me to the 
service in the almshouse. Foundlings were received nearly every day, and 
were given cow's milk prepared by these pauper women. When my duties 
commenced in the almshouse the deaths corresponded with the admissions : 
only one infant was pointed out that had survived the first half year in 
the almshouse. 

These facts, to which others might be added from the experience of 
European cities, show the importance of wet-nursing as a means of reducing 
infantile mortality in the cities. What has been stated as regards the result 
of artificial feeding of foundlings is true, in great measure, in reference to all 
city infants. The ill-effect of artificial feeding is well known in city families, 
and it is the common practice to employ a hired wet-nurse if, for any reason, 
the mother's milk is insufficient. 

When the infant has reached the age at which it is proper to wean, the 
digestive organs are less frequently deranged by errors of diet. More sub- 
stantial food, and considerable variety in it, may now be not only safely 
allowed, but are required by the wants of the system. 



CHAPTER IV. 

WEIGHT, GKOWTH, TEMPERATUBE, PULSE, RESPIRATION. 

Dr. K. Parker, resident physician of the New York Infant Asylum 
when these observations were made, weighed, immediately after birth, 170 
infants— 89 male and 81 female — born consecutively and at term, with the 
following result : 

Average male weight 7 lbs. 11 oz. 

female " 7 " 4 " 

Fifty of these, who were wet-nursed and apparently well taken care of, were 
weighed when one week old, with the following result : 

Increase of weight in 32 cases. 

Loss of weight in 13 " 

Average gain 4 T 8 o oz. 

" loss 3£ " 

Greatest gain 12° " 

" loss 6 " 

Average Gain. 

From birth to age of 4 months (25 cases) 4 lbs. 8| oz. 

" 3 to 6 months (6 cases) 3 " 3i " 

" 6 to 9 " " 2 " 7* " 

" 9 to 12 " " i « 151 « 



WEIGHT, GROWTH, TEMPERATURE, PULSE, RESPIRATION. 27 

Statistics of Temperature, Pulse, and Respiration of Healthy In- 
fants, OBTAINED BY DRS. PARRY AND HODGE, N. Y. INFANT ASYLUM. 



Age. 
Under 6 mos. 

6 to 12 mos. 

12 to IS mos. 

18 to 30 mos. 



Table I. — Temperature in Health. 
J Rectal average of 313 observations in 14 children, 98.5°. 



\ Axillary 
f Rectal 
\ Axillary 
l Rectal 
\ Axillary 
f Rectal 
1 Axillary 



144 
55 
39 
70 
35 

102 
54 



14 


98.3°. 


2 


98.6°. 


2 


98.3°. 


2 


98.4°. 


2 


98.3°. 


3 


98.9°. 


3 


' 98.1°. 



The difference in the temperature of healthy infants in the morning and 
evening was found to be trivial, as is seen by the following statistics : 



Morning and Evening Temperatures. 



6 to 12 mos. | Rectal average, a. m. 
12 to 18 mos. { Ee( * al av ^ e > £• £ 
18 to 30 mos. { Ee( * al ave ™ ge ' p ' £" 



98.44 (observations, 436). 
98.56 ( " 414). 

98.43 (observations, 185). 
98.34 ( " 181). 

98.34 (observations, 206). 
98.59 ( " 199). 



No. of infants, 6 
6 
4 
4 
3 
3 



Table II. — Pulse in Quiet, Health?/ In/ants. 

Under 6 mos., observations 90, No. of infants 27, average 125 
6 to 12 " " 11, " " 2, " 124 

12 to 18 " " 23, " " 4, " 115.5 

18 to 30 " " 37, " " 7, " 111.8 

Respirations. 

Under 6 mos., observations 90, No. of infants 27, average 44.8 
6 to 12 " " 11, " " 2, " 34.8 

12 to 18 " " 24, " " 4, " 35.4 

18 to 30 " " 37, " " 7, " 29.8 



Average Pulse. 

When awake. 

Under 6 mos 141.77 . 

6 to 12 " 136.2 . 

12 to 18 " 129.8 . 

18 to 30 " 



When asleep. 
. . 128.23 
. . 120.37 
. 110.71 



131.6 108.35 



Respirations. 

Awake. Asleep. 

Under 6 mos 53.47 40.23 

6 to 12 " 41.66 32.13 

12 to 18 " . 38.25 26.18 

18 to 30 " 39.33 25.49 



Lactation. — It is desirable that the infant as soon as it requires nutriment 
should receive breast-milk. If it be fed for a few days with the bottle or 
spoon, it may be difficult finally to induce it to take the breast ; therefore it 
is well to determine early whether the mother will be able to wet-nurse her 
infant, so that, if unable, suitable provision may be made. 

The matter of determining beforehand the capability of the mother for 
wet-nursing has been investigated by Dr. Donne of Paris, and in his treatise 
on Mothers and Infants he describes the mode in which it may be ascertained. 
The desired information, in his opinion, may be acquired by examining the 



28 INFANCY AND CHILDHOOD. 

colostrum, which is secreted in small quantity in the last months of gesta- 
tion, and which can be squeezed from the breast in sufficient quantity for 
inspection. 

In some women, according to Dr. Donne, the colostrum is so scanty that 
only a drop or half a drop can be obtained from the nipple by careful pres- 
sure. This will be found by the microscope to contain but few milk-glob- 
ules, ill formed, and a few granular bodies, such as the colostrum ordinarily 
contains. Such women almost invariably furnish poor milk and in small 
quantity. In other women the colostrum is abundant, but thin, resembling 
gum-water ; it lacks the yellow streaks and viscous character of ordinary 
colostrum, and it flows readily from the nipple. The milk of such women 
is sometimes scanty, sometimes abundant, but it is watery and deficient in 
nutritive principles. In a third class of women the colostrum is pretty abun- 
dant, and it contains yellowish streaks of more or less consistence, which are 
found to be rich in milk-globules of good size. Women furnishing such 
colostrum in the last weeks of gestation will have sufficient milk and of 
good quality. These latter women make the best wet-nurses. 

Wet-nursing: its Advantages and Hindrances; Physical Condi- 
tions rendering it Improper. 

During the first year of the infant's life the natural mode of alimenta- 
tion — that by the mother's milk — should always be recommended, except 
in those instances in which mothers are incapacitated by physical ailments 
or mental derangement. The practice common in New York, and probably 
in other cities, of employing wet-nurses, in the belief that suckling their 
infants deprives mothers of social enjoyments and by the drain upon the 
system impairs their general health, should be discouraged. Wet-nursing 
by the mother, if properly regulated, with sufficient undisturbed sleep at 
night, and with the maintenance of good appetite and digestion, does not 
impair her health, but, on the other hand, tends to promote her physical 
well-being. But there are unavoidable conditions which render wet-nursing 
by the mother injudicious or impossible. These will be considered hereafter. 

The primipara often experiences difficulty in wet-nursing in consequence 
of a depressed state of the nipple. It is not sufficiently prominent to be 
readily grasped by the mouth, and after ineffectual attempts the infant 
becomes fretful when applied to the breast, and perhaps for a time refuses 
it altogether. Multipara occasionally experience the same inconvenience, 
but it is not common when there has once been successful lactation. By 
calmness and perseverance on the part of the mother the nursling can usually 
be made to seize the nipple in the course of a week. 

Depression of the nipple is, to a certain extent, the result of pressure 
upon it by the dress during gestation. The state of the nipple should 
indeed, in those who have never suckled, receive early attention, even before 
the birth of the infant. Tightness of dress around the breast, as also upon 
every part of the body, should be avoided, and from time to time gentle 
traction should be made upon the nipple if it be depressed. It may be 
drawn out by the fingers of the mother several times each day, or by a com- 
mon breast-pump, or by suction with a tobacco-pipe, the edge of the bowl 
having been smoothed. Occasionally, in these cases of depressed nipple 
the mother, fatigued and discouraged by her frequent ineffectual attempts 
to induce the infant to nurse, becomes feverish and excited, so that the quan- 
tity of her milk is sensibly diminished. The physician should assure her, as 
he usually can with confidence, that in a few days, as the baby becomes a little 
stronger, there will be no difficulty in its nursing. Some women are unre- 



WET-NUESING. 29 

mitting in their endeavors to procure nursing. This should be forbidden, 
since the lack of sleep and the nervousness which such constant endeavor 
produces tend to defeat the object which they have in view, by diminishing 
the secretion of milk. Sufficient sleep, freedom from anxiety, and no more 
frequent application of the infant to the breast than is required in success- 
ful lactation should be enjoined. Occasionally, we can best succeed in pro- 
curing lactation under these circumstances of discouragement by the aid of 
another infant older, more vigorous, and better able to seize the nipple. An 
exchange of infants a few times may remedy the difficulty. 

Occasionally, suckling is rendered difficult and painful by too long delay 
before applying the infant to the breast. When the mother has rested a few 
hours after her confinement — about six in ordinary cases — lactation may com- 
mence. There is at first but very little milk, often only a few drops, but the 
secretion is promoted by nursing, so that the requisite amount is sooner 
obtained than when the infant is kept from the breast till the second or third 
day. If, as some physicians advise, suckling be deferred till the breasts are 
full and tender, and if, as is often the case with primiparse, the nipples are 
also tender ; many mothers lack the fortitude required to allow their infants 
to obtain a sufficient amount of milk. Excoriated and fissured nipples con- 
stitute a serious impediment to wet-nursing. They are very sensitive on pres- 
sure, and are long in healing. They are fully described in works which relate 
to female diseases, and their treatment pointed out. Occasionally, fissured 
nipples do harm to the infant by the blood which escapes and is swallowed 
with the milk. A case is related in which positive indigestion was caused 
in this way, the infant vomiting, after each nursing, milk mixed with blood. 
The local hindrances to lactation described above can in most instances be 
relieved in the course of a few weeks. To what extent menstruation and 
pregnancy are detrimental to the nursing, and therefore contraindicate lacta- 
tion, will be considered in another section. 

There is occasionally a constitutional state of the mother which necessi- 
tates either the employment of a hired wet-nurse or weaning. This is the 
case when there is a strong tendency to tuberculosis. If the complexion be 
pallid, the system at all emaciated, and suckling be attended by more or less 
exhaustion, and if with fair trial of wine and tonics no improvement follow, 
the physician is justified in forbidding further attempts at wet-nursing. If, 
under such circumstances, an hereditary tendency to tuberculosis exist, it is 
his duty positively to interdict nursing. The opinion of the physician in such 
a matter should be formed after mature deliberation. There are many women 
who, suffering temporarily from illness and discouraged, are ready at once to 
abandon their infants to the care of others with the least encouragement on 
the part of the physician to do so, but who, by attention to their own health, 
and especially by taking more sleep, soon recover from their depression and 
become good wet-nurses. On the other hand, night-sweats, a cough, and pro- 
gressive decline in health show the need of immediate suspension of wet- 
nursing. 

Sometimes women prior to pregnancy present indubitable evidence of 
tuberculosis, but by the improved general health which attends pregnancy 
the disease is temporarily arrested. Such women should never suckle their 
infants. If they do, they soon lose all that was gained and the disease 
advances rapidly. These objections to wet-nursing in such a state of health 
apply to the mother. There are also objections as regards the infant. The 
milk of those in decidedly infirm health is deficient in nutritive principles. 
Their infants, therefore, are ill-nourished, and if they have inherited a pre- 
disposition to tuberculosis, there is great danger that this disease will be 
developed in them; whereas with healthy wet-nursing even a strong predis- 



30 INFANCY AND CHILDHOOD. 

position may remain latent. M. Donne relates the following instructive cases,, 
which show the danger which sometimes attends suckling and the imperative 
necessity which may arise of discontinuing it : " A very light-complexioned 
young mother, in very good health and of a good constitution, though some- 
what delicate, was nursing for the third time, and, as regarded the child, 
successfully. All at once this young woman experienced a feeling of 
exhaustion. Her skin became constantly hot ; there were cough, oppression, 
night-sweats ; her strength visibly declined, and in less than a fortnight she 
presented the ordinary symptoms of consumption. The nursing was immedi- 
ately abandoned, and from the moment the secretion of milk had ceased all the 
troubles disappeared." "A woman of forty years of age, .... having lost, 
one after another, several children, all of whom she had put out to nurse, 
determined to nurse the last one herself. .... This woman, being vigorous 
and well built, was eager for the work, and, filled with devotion and spirit, 
she gave herself up to the nursing of her child with a sort of fury. At 
nine months she still nursed him from fifteen to twenty times a day. 
Having become extremely emaciated, she fell at once into a state of weak- 
ness from which nothing could raise her, and two days after the poor woman 
died of exhaustion. '" 

A very similar case recently occurred in my practice. A young and 
healthy woman from the country, suckling her second infant, on coming to 
the city lived in a dark and very imperfectly ventilated room on the first floor 
and in the rear of a crowded tenement-house. She soon lost her appetite, 
but continued suckling for three months, when she became so ansemic and 
feeble that she was compelled to seek medical advice. She died without local 
disease, notwithstanding the most nutritious diet and free use of stimulants 
and tonics. 

Constitutional syphilis in the mother does not contraindicate wet-nursing. 
It is probable that the infant also has it. The mother should take antisyph- 
ilitic remedies, which will eradicate the disease in herself, and also, if it be 
present, in the infant. Febrile affections also do not in general contraindicate 
wet-nursing. They may, however, for a time diminish, the quantity of milk 
or impair its quality. If,' however, the mother be in a critical state or much 
reduced, whatever the disease, suckling should cease. Whether or not the 
infant should be taken from the breast if the mother be suffering from one 
of the essential fevers depends on the severity of the malady and the degree 
of her exhaustion. Twice I have known newly-born infants to be suckled by 
mothers while the latter had scarlet fever without contracting it, but suffer- 
ing immediately afterward from protracted and severe eczema. In rural 
localities, where artificially-fed infants, as a rule, do well, it might be best to 
wean if the mother have such a disease ; but in the city eczema is less dan- 
gerous than the diarrhoeal affections which early weaning is likely to entail. 
In most cases of typhus and typhoid fevers weaning or procuring a wet- 
nurse is necessary, on account of the depression of the vital powers which 
these diseases produce. Mothers with organic diseases, of whatever kind, 
which impair the general health or diminish the appetite, should never be 
allowed to wet-nurse their infants. Wet-nursing under such circumstances is 
likely to aggravate the disease, and the milk which such mothers furnish, 
even if sufficient in quantity, is deficient in nutritive properties. 

Inflammatory affections, unless of a dangerous character. _do not ordinarily 
interfere with wet-nursing, except that the quantity of milk is somewhat dimin- 
ished. In severe inflammation it may be so necessary to husband the strength 
or to keep the patient perfectly quiet that suckling her infant would be inju- 
dicious. It should then be transferred to a wet-nurse or weaned. Inflam- 
mation of the breast often presents an impediment to lactation. It is a 



HINDRANCES TO LACTATION 31 

common and painful affection, suspending or greatly diminishing the secre- 
tion of milk in the affected gland. Wet-nursing should cease as soon as there 
are evident signs of inflammation, unless it be limited to a small part of the 
gland. General heat of the breast, with tenderness and induration extending 
over a considerable part of it, indicates the need of the immediate removal 
of the infant from it. Suckling must be restricted to the unaffected side. 
It is often the case that the volume of the inflamed gland is considerably 
increased from the afflux of blood to it and from the interstitial exudation, 
while it contains little or no milk, and attempts at suckling under such cir- 
cumstances are injurious to the mother as well as to the infant. The cause 
of the swelling should be explained to the mother, who commonly attributes 
it to the accumulation of milk, and worries herself and the infant by attempts 
to make it nurse. As the inflammation abates by resolution, or more com- 
monly by suppuration, and the normal secretion returns, the first milk, which 
is usually thick and stringy, should be rejected, after which the infant may 
nurse as usual. Occasionally, the abscess which has formed in the breast 
connects with a lactiferous tube, so that pus may, on suction, escape from 
the nipple. If this occur, of course nursing should be interdicted until pure 
milk is obtained. Pus in the milk can sometimes be detected by the naked 
eye. It presents a yellowish or greenish color, occurring in streaks when not 
intimately mixed with the milk. When it is intimately mixed and in small 
quantity, it cannot be detected by the naked eye, but the microscope reveals 
the pus-globules. M. Donne relates a case in which he discovered these 
globules by the microscope, although there were at first no other evidences 
of an abscess, and doubts were expressed in reference to the accuracy of his 
observation. Finally, an abscess pointed and discharged. 

Sometimes when the inflammation abates the secretion does not return, 
and, worse still, occasionally the inflammation has occurred so near the nipple 
that the lactiferous tubes are permanently closed by it, so that, though milk 
form in the breast, there is no escape for it. Thenceforth only one breast can 
be used. 

If erysipelas occur in the mother, the infant should be immediately taken 
from her breast and from her arms. If this disease should not be communi- 
cated to the infant through the* milk or through fissures in the nipple, of 
which there is danger, still the milk usually undergoes such a change in con- 
sequence of the erysipelas as to endanger the health of the child. Thus, one 
of the wet-nurses in the New York Infant Asylum sickened with severe facial 
erysipelas on the 24th of April, 1875, eight days after the death of her baby. 
She was wet-nursing a foundling, aged seven weeks, at the time of the com- 
mencement of the erysipelas, and, as it was very important that her milk 
should be preserved for the coming hot months, it was deemed best to allow 
the nursing to continue, the infant being placed in a crib at a little distance 
as soon as it dropped the nipple. On the 27th the baby was troubled with 
diarrhoea. April 28th its morning temperature was 101°, and that of the 
evening 103°, the diarrhoea continuing. It was now removed entirely from 
the breast and was given artificial food. On the 29th there was a decided 
general icteric hue of the infant's surface, which continued till its death on 
May 1st. The stools numbered about eight daily till April 30th. when they 
ceased. The record which I preserved does not state whether there was 
vomiting, but it had probably been slight on account of the speedy prostra- 
tion. Death occurred from exhaustion. At the autopsy from half an ounce 
to one ounce of pus was found in the peritoneal cavity, newly-formed fibrin 
was observed upon the spleen and liver, and the peritoneum generally had 
lost much of its lustre : a careful microscopic examination of the liver and 
its ducts, made by Dr. Heitzmann, revealed no anatomical change which would 



32 



INFANCY AND CHILDHOOD. 



explain the icteric hue, and it seemed propable that this was due to the altered 
state of the blood. The mucous membrane of the intestines exhibited vascular 
streaks and its follicles were distinct. The lesions, therefore, indicated intes- 
tinal catarrh. Nothing unusual was observed in the heart and lungs of the 
infant. Its life had been apparently sacrificed by the unhealthy nursing. 



Colostrum. 

The milk secreted during gestation and immediately after the birth of the 
infant ordinarily diifers in its gross appearance, as well as chemical and 
microscopical characters, from that which is subsequently secreted. It is 
termed colostrum. It has a turbid and yellowish appearance, and is some- 
what viscid. It is decidedly alkaline, and undergoes lactic-acid fermentation 
more readily than common milk, and it also contains more solid matter. 1+ 
has an excess of fat, of salts, and, according to Simon, also of sugar. J > 
appears from Simon's analysis that the solid matter of colostrum is about 
17 per cent., while that of the ordinary breast-milk is about 11 per cent. 

Examined by the microscope, the colostrum is seen to contain oil-globules 
and a viscid substance which often assumes an ovoid or globular form, but 
which also exists in irregular masses of considerable size. This substance 
has been thought by some to be mucus, but it is dissolved by acetic acid and 
potash and is tinged yellow by a watery solution of iodine. It is therefore 
to be regarded as albuminous. Imbedded in this substance are oil-globules, 
which are for the most part of small size, while the free oil-globules of colos- 
trum are larger than those occurring in healthy milk. The viscid substance, 
with the imprisoned oil-globules, constitutes what has been designated the 
" colostrum-corpuscles." 

The colostrum is replaced by milk of the normal character in six to eight 

Fig. 2. 



Fig. 1. 









Oo G ' 

Co & <D 






Milk-globules. 









Colostrum-corpuscles. 



-days, sometimes as early as the third or fourth day after delivery. In excep- 
tional instances the colostrum does not disappear for several weeks, and it 
may reappear at any time subsequently as a consequence of derangement of 
the system or from disease. It is assimilated with difficulty by the digestive 
organs of the infant, producing usually a laxative effect. It therefore aids 
in the removal of the meconium, and, being a normal production, it is to be 
regarded as beneficial in the first week of the infant's life. Continuing longer 
than the first week, its effect is deleterious. It produces evident derange- 
ment of the digestive organs, and the infant that habitually nurses it never 
thrives. It has diarrhoea or vomiting, becomes more or less emaciated, and 
suffers from colicky pains. Sometimes an extreme degree of exhaustion is 
reached before the cause is suspected, for if the milk be pretty abundant the 



HUMAN MILK. 33 

admixture of colostrum with it cannot be detected by the naked eye. The 
microscope alone reveals it. The following is an interesting example of this 
fact : In 1SGS an infant six weeks old was brought to me with the following 
history : The mother had for several years been troubled with dyspeptic 
symptoms, but had otherwise been in good health. The infant at birth was 
fleshy and strong, but after the first week it had never thrived like other 
infants. It nursed regularly, and the quantity of milk was apparently suf- 
ficient, but it vomited as soon as it ceased nursing; it was much emaciated 
and the bowels were habitually constipated. The digestive organs of the 
infant had been in this unhealthy state, with little variation, from the first 
week, and it was very evident, from the emaciation and exhaustion, that it 
must soon perish unless some change were effected. The milk of the mother 
^resented the usual appearance to the naked eye, but under the microscope 
colostrum-corpuscles were observed. A wet-nurse was immediately obtained, 
f id from that moment the gastro-intestinal symptoms disappeared, with a 
rapid recovery. This case shows at once the evil effects of the colostrum 
aDd the need of a microscopic examination of the milk whenever the nursling 
suffers from indigestion. 



*&' 



Human Milk. 

In the normal state milk is the sole nutriment during the first months of 
infancy, and during the entire periods of infancy and childhood it contributes 
more than any other food to healthy development and growth. It contains 
nitrogenous elements designed for tissue-formation, along with carbohydrates, 
fats, saline substances, and abundant water, designed for sustaining the heat, 
producing cell-formation, and the various secretions and excretions. All the 
ingredients of milk are useful in one way or another in the economy, so that 
there is no waste as in other kinds of food. 

Foster states that milk is the result of the activity of certain protoplasmic 
cells forming the epithelium of the mammary gland. " So far as we know, 
the fat is formed in the cell through metabolism of the protoplasm. Micro- 
scopically, the fat can be seen to be gathered in the epithelium cell in the 
same way as in a fat-cell of the adipose tissue, and to be discharged into the 
channels of the gland, either by a breaking up of the cells or by a contractile 
extrusion very similar to that which takes place when an amoeba ejects its 
digested food." Foster also states that there is evidence that the casein and 
sugar are formed from the protoplasm in the mammary cells, and not by 
appropriation of the casein and sugar introduced into the system in the food. 
Therefore, if the food contain no fat, casein, or sugar, still, these substances 
are produced by the cell-agency in the mammary gland (Arch, fur Pliys., 
1886, 539). 

According to MM. Vernois and Becquerel, the average specific gravity 
of human milk in 89 observations was 1032, the minimum being 1025 and 
the maximum 1046. The specific gravity of cream from milk having the 
sp. grav. 1032 is 1024 ; of the milk skimmed, 1046. Of course many cir- 
cumstances cause modifications in human milk, as irregularities in the mode 
of life, excesses, lack of requisite sleep, food too highly stimulating or defi- 
cient in nutritive properties, etc. 

The analysis of human milk has been made with great care by different 
chemists. Its composition of course varies considerably in different females 
according to the diet, health, mode of life, etc., but the following table, pre- 
pared by Robin and accepted by Prof. Austin Flint in his elaborate treatise 
on physiology, gives the most reliable exhibit of its composition yet pub- 
lished : 



34 INFANCY AND CHILDHOOD. 

Composition of Human Milk. 

Water 902.717 to 863.149 

Casein (desiccated) 29.000 " 39.000 

Lacto-proteine 1.000 " 2.770 

Albumin traces " 0.880 

f Margarine 17.000 " 25.840 

Butter 25 to 28 1 Oleine 7.500 " 11.400 

[_ Butyrine, Caprine, Caproine, Capriline . 0.500 " 0.760 

Sugar of milk (lactose) 37.000 " 49.000 

Lactate of soda (?) 0.420 " 0.450 

Chloride of sodium .• 0.240 " 0.340 

Chloride of potassium 1.440 " 1.830 

Carbonate of soda 0.053 " 0.056 

Carbonate of lime 0.069 " 0.070 

Phosphate of lime 2.310" 3.440 

Phosphate of magnesia 0.420 " 0.640 

Phosphate of soda 0.225 " 0.230 

Phosphate of iron (?) 0.032 " 0.070 

Sulphate of soda 0.074" 0.075 

Sulphate of potassa a trace 

f Oxygen, 1.29 ^ 

Gases in solution < Nitrogen, 12.17 y 30 parts per 1000 volume. 



f Oxygen, 1.29 ^ 

•j Nitrogen, 12.17 y 

(. Carbonic acid, 16.54 J 



Modification of Milk in Consequence of the Diet. 

The relative proportion of the different ingredients of the milk varies 
according to the diet. If the diet be poor, the amount of water increases 
and that of butter and casein diminishes. Lehmann says (Phys. Chemistry, 
vol. ii. p. 65) : " From experiments made on bitches it would appear that a 
vegetable diet renders the milk richer in butter and sugar, while the solid 
constituents are augmented when a sufficient quantity of mixed food is given. 
Peligot found the milk of an ass most rich in casein when the animal had 
been fed on beet-root, while it was richest in butter when the food had con- 
sisted of oats and lucerne. Boussingault found the milk of a cow richer in 
casein when the animal had been fed on potatoes than when other food was 
taken. Reiset found that the milk of cows which were at grass was much 
richer in butter than when the animals had stood all night in their stall with- 
out food ; but Playfair found, on the contrary, that the quantity of butter in 
the milk increased during the night as much as during their stall-feeding, but 
that the quantity of butter in the milk was considerably diminished by the 
motion of the animals in the fields." l Simon made the following analysis of 
the milk of a poor woman. She was suddenly, during the period of lactation, 
deprived of the means of support, so that her food was insufficient in quantity 
and of poor quality. The amount of her milk was not diminished by priva- 
tion, but the solid constituents were reduced to 86 parts in 1000. After this, 
for a time, her diet was nutritious and abundant, the quantity of milk was 
increased, and the solid constituents amounted to 119 parts in 1000. Her 
diet was again reduced, with a reduction of the solid elements to 98 in 1000, 
and at a later period the diet was again nutritious, with an increase of the 
solid elements to 126. The chief variation observed in the milk of this 
woman was in the amount of butter. 

Modification of Milk from its Retention in the Breast. 

M. Peligot has clearly demonstrated that the longer milk is retained in 
the breast the more watery it becomes. This is explained on the supposition 

1 Animal Chem., Sydenham Soc.'s Trans., vol. ii. p. 55. 



MODIFICATION OF MILK BY VARIOUS CAUSES. 35 

that the solid portion is first absorbed. Therefore, the milk is richer the more 
frequently it is removed from the breast. A similar fact, which has the same 
explanation, has long been known — namely, that the first milk taken from the 
breast is thinnest, while that which flows last is richest. That first removed 
has remained longest in the gland, while that which comes last is but recently 
secreted. 

A knowledge of this fact is of considerable practical importance. The 
milk, as M. Donne has shown, may be too rich, so as to cause indigestion, 
with more or less enteralgia, in the infant. Some nurslings, if the milk be 
too rich and abundant, reject a part of it by vomiting, but others do not, and 
suffer the consequence of derangement of the digestive organs. For such 
cases the remedy is to give the breast less frequently, by which a less amount 
of milk is taken and milk of a poorer quality. On the other hand, if there 
be poverty of the milk and the infant be insufficiently nourished, the milk is 
more nutritious if the nursing be at short intervals. 

Modification of Milk by Age and by Mental Impressions. 

The composition of milk varies also according to the age of the infant. 
Simon analyzed the milk of a woman at intervals for the period of about six 
months. In this case the amount of casein at first was small, but the quan- 
tity increased during the two months succeeding delivery, after which it was 
nearly stationary. A similar increase was observed in reference to the saline 
substances. The sugar, on the other hand, diminished in quantity as the 
infant grew older, its maximum amount being in the first and second months. 
The quantity of butter in the milk varies from day to day more than the 
other elements. 

Many observations have been published which show that the composition 
of the milk may be materially changed by mental impressions. The infant 
has died suddenly in the act of nursing after its mother had been violently 
excited. Such a case is related by Tourtnal. The infant ceased nursing, 
gasped, and died in the mother's lap. In other cases convulsions have 
occurred. MM. Becquerel and Vernois made the chemical analysis of the 
milk of a woman in a state of nervous excitement, and found that the solid 
constituents were diminished to 91 parts in 1000, the most marked diminu- 
tion being in the butter, which was only about 5 parts. In a case related by 
Parmentier and Deyeux the milk became watery and viscid, and remained so 
till the nervous attacks from which the patient suffered had ceased. Dairy- 
men are well aware how ill-treatment and the separation of the calf from the 
cow diminish the milk which she yields. A new milkman seldom obtains as 
much milk as one with whom the cow is familiar. Bouchut, alluding to the 
influence of the moral affections on the secretion of milk, makes the follow- 
ing remark, the truth of which most mothers will acknowledge : " It is also a 
fact that the sight of the nursling, the idea of seeing it at the breast, and the 
joy which certain mothers thence experience, exercise a moral influence over 
the secretion of the milk entirely independent of their will. They feel the 
draught of milk as soon as they behold their child or think of it too deeply : 
and in a woman who saw her child fall to the ground the flow of milk ceased. 
and did not reappear until the child, having quite recovered, attempted to 
take the breast." 

Rotch states that a primipara of an excitable and nervous temperament 
was in a marked degree anxious and despondent in reference to her infant. 
which she was wet-nursing. The infant began to suffer from indigestion, so 
that the mother's milk was analyzed with the following result : water. 89.17 ; 
fat, 0.62; sugar, 5.80; albuminoids, 4.21 ; ash, 0.20. " This marked variation 



36 INFANCY AND CHILDHOOD. 

from normal milk was apparently due to the emotions of the mother. A wet- 
nurse was procured and the infant did well. 

Modification of Milk by the Catamenial Function, Pregnancy, 

and Other Causes. 

The catamenia reappear in most women before the close of lactation, often 
by the fifth or sixth month after delivery. If this function be re-established 
in the normal manner — that is, without any derangement of the system, with- 
out pain or undue profuseness — no unfavorable result ordinarily occurs with 
the infant, On the other hand, if the mother suffer any disturbance of the 
system or if the menses be profuse, the lacteal secretion may be so changed 
that the infant is injuriously affected by it. The symptoms produced are 
those of indigestion, such as abdominal pains, more or less vomiting, and 
diarrhoea. This result is, however, in my experience, quite exceptional. In 
rare instances more dangerous symptoms occur in the infant. A case has 
been reported to me in which at each catamenial period the nursling was 
seized with convulsions. 

Charles Marchand found in three chemical analyses of the milk during 
menstruation a diminution of 2 to 4 parts in the butter, of 2 to 5 parts in 
the sugar, and a diminution in the casein and albumen of 2 to 5 parts. This 
seems but a trifling change when we recollect that human milk in the state 
of health contains, according to the analysis of M. Robin and others, 25 to 

37 parts of butter, 37 to 49 parts of sugar, and 29 to 39 parts of casein in 
1000 of milk. Rotch has made the following analyses of the milk of two 
women during the catamenia, Their infants exhibited symptoms of indi- 
gestion during, but not before or after, the catamenial flow : 

First Case. Second Case. 

Fat 0.62 1.37 

Sugar 5.80 6.10 

Albuminoids 4.21 2.78 

Ash .20 0.15 

Solids 10.83 10.40 

Water 89.17 89.60 

{Cyclop, of Diseases of Children, 1889.) 

In these two instances the albuminoids were increased. But even if the 
infant suffer from indigestion during the catamenial period, its duration is so 
short and the milk so soon returns to its normal state that the occurrence of 
the catamenia does not indicate the need of weaning if the infant be under 
the age of ten months. But if the menses reappear with regularity when 
the infant has attained the age of ten or twelve months, they should be con- 
sidered as designed to supersede the secretion of milk, which, indeed, usually 
begins to diminish. Weaning is then proper. If the menses return early in 
the period of lactation and give rise to symptoms in the infant in consequence 
of the altered quality of the milk, it is best to allow but little nursing during 
the catamenia, and to employ artificial feeding instead until the flow of blood 
ceases. 

The change produced in the milk by pregnancy is, in general, more inju- 
rious to the nursling than that caused by the reappearance of the menses. 
The milk of the pregnant woman frequently contains more or less of the 
viscid substance which characterizes colostrum. Still, the milk of pregnancy 
does not ordinarily derange the digestive function as much as colostrum in 
the first weeks of lactation, for pregnancy rarely occurs till after the infant 
is five or six months old, when the organs of digestion are less readily dis- 
turbed. The injurious effect of pregnancy on the infant is shown by vomit- 



MODIFICATION OF MILK BY VARIOUS CAUSES. 37 

ing or diarrhoea, by restlessness and occasional abdominal pains ; in fine, by 
symptoms of indigestion. In many cases, however, these symptoms do not 
occur, and the infant, though nursing regularly, continues to thrive. Xo 
doubt, as a rule, the nursling should be weaned when there are clear evi- 
dences of pregnancy, but under certain circumstances weaning is injudicious. 
I have on different occasions been called to infants in midsummer dangerously 
sick with diarrhoeal attacks induced by this cause. These infants were per- 
haps doing well or suffering but little from indigestion, when the mothers, 
suspecting themselves pregnant, at once withdrew them from the breast, and 
severe and dangerous intestinal catarrh was the result. No infant in the 
city should be weaned in the hot months. It is much safer, though there be 
indubitable signs of pregnancy, that it continue nursing till the cool weather. 
The better method is, however, under such circumstances to employ a wet- 
nurse or to remove the infant to the country and wean it there. In cool 
weather it is usually safe to wean an infant in the city after it has reached 
the age of five or six months. 

Sometimes a young mother devotes herself unremittingly to the care of 
her infant, giving it the breast every hour or oftener through the day and 
frequently through the night. She gives the infant little rest, and has but 
little herself. This devotion, praiseworthy as it is, is nevertheless very 
injurious to both parties concerned. The rule should be repeated and remem- 
bered, that while an infant may nurse hourly during the first month, except 
in the hours which the mother requires for sleep, in which it should not nurse 
more than once or twice, after the first month nursing should be restricted to 
intervals of two hours till the third or fourth month, and in older infants, 
with greater capacity of the stomach, to intervals of three or four hours. 
Too frequent nursing produces indigestion with its usual fretfulness and 
diarrhoea, and it deprives the mother of the mental composure and rest which 
are required for successful lactation ; but the more the infant frets, in many 
instances, the oftener the mother applies it to the breast, which only increases 
the indigestion. Worriment and lack of sleep tend not only to diminish the 
milk, but also to impair its quality. 

Effect of Medicine on the Mother's Milk. 

This important subject has been investigated by Fehling (Arch./. Gyn., 
xxvii. p. 332). According to him, one or two grammes of salicylate of 
sodium, taken by a woman who is wet-nursing, may be in part recovered 
in the child's urine. Rheumatism in the nursing child may therefore be 
treated by the ordinary doses of this agent administered to the mother. 
Rheumatism occurs more frequently in the nursing infant than is commonly 
supposed, since its symptoms as regards the joints are usually mild and 
likely to be overlooked, and it often causes endocarditis and permanent 
valvular disease when its presence is not suspected and no physician is 
called. Schaeffer relates the case of an infant born with rheumatism. 
Iodide of potassium also, says Fehling, given to the mother, can be detected 
in large quantity in the infant's urine. We have Fehling's authority for the 
following statements : After applying iodoform to perineal lacerations, iodine 
was found in the milk and urine of the mother, but no apparent harm has 
resulted from applying iodoform to wounds or sores in the nursing mother. 
Mercury taken by the mother did not appear in the milk, and the same was 
true of acetic, hydrochloric, and citric acids. Therefore acid foods probably 
do not render the milk acid. Laudanum given by the mouth in no instance 
caused drowsiness in the infant, and morphia given hypodermically did not. 
as a rule, affect the child. On the other hand, atropine taken by the mother 



38 INFANCY AND CHILDHOOD. 

caused dilation of the infant's pupils. Hydrate of chloral taken by the 
mother did not affect the child. The effect on the nursing child of medi- 
cines administered to the mother needs further investigation. The observa- 
tions relating to it published in the journals are as yet too meagre for the 
valid and reliable deductions which are required by the profession to ensure 
safe and proper medication of nursing women. 

Differences in Women as regards Quantity and Quality of Milk. 

There is a great difference in different women as regards the quantity and 
quality of their milk, and even the mode in which it is secreted. The best 
wet-nurses are usually robust without being corpulent. Their appetite is 
good, and their breasts are distended from the number and large size of the 
blood-vessels and milk-ducts. There is but a moderate amount of fat around 
the gland, and tortuous veins are observed passing over it. Such nurses do 
not experience a feeling of exhaustion and do not suffer from lactation. 

The nutriment which they consume is equally expended in their own sus- 
tenance and the supply of milk. There are other good wet-nurses who have 
the physical conditions which I have described, but whose breasts are small. 
Still, the infant continues to nurse till it is satisfied, and it thrives. The milk 
is of good quality, and it appears to be secreted mainly during the time of 
suckling. Other mothers evidently decline in health during the time of 
lactation. They furnish milk of good quality and in abundance, and their 
infants thrive, but it is at their own expense. They themselves say, and 
with truth, that what they eat goes to milk. They become thinner and paler, 
are perhaps troubled with palpitation, and are easily exhausted. They often 
find it necessary to wean before the end of the usual period of wet-nursing. 
There is another class whose health is habitually poor, but who furnish the 
usual quantity of milk without the exhaustion experienced by the class 
which I have just described. The milk of these women is of poor quality. 
It is abundant, but watery. Their infants are pallid, having soft and flabby 
fibre. All these kinds of wet-nurses are met in practice, and they require 
general sustaining measures, but the treatment must be more or less diverse 
according to the exigencies of each case. 

Rules in regard to Lactation. 

Newly-born infants should be applied to the breast about twelve times in 
twenty-four hours. The suckling should be mostly in the day-time, and only 
once or twice during the hours required by the mother for sleep. After the 
third or fourth week the infant should take the breast at intervals of two 
hours during the day-time, and only once during the seven or eight hours of 
sleep which the mother must have in order that her health be preserved and 
her milk be of good quality. A healthy infant empties the breast in ten to 
fifteen minutes of nursing, when it should be removed, and if in good condi- 
tion it falls asleep, and may not awaken until the next suckling, or if it 
remain awake it is cheerful and contented. 

Insufficient Feeding of the Neirfy-born. — Not a few young infants perish 
from want of food, even in well-to-do families who are solicitous for the wel- 
fare of their children and are abundantly able, pecuniarily, to provide the 
nutriment which they require. During the last two or three years I have 
been called to four or five new-born babies whose mothers were primiparse, 
young and inexperienced — babies that were said to be hearty nursers until 
they became too weak to draw the breast. The history received was, that 
they never seemed satisfied, fretted almost constantly, quiet when drawing 
the breast for a short time, but crying and sleepless immediately afterward, 



BULES IN REGARD TO LACTATION. 39 

losing in weight and strength each day. The urine was scanty and the stools 
infrequent. The condition was one of gradual starvation. When summoned 
to these cases I have found in one instance no pulse at the wrist of the baby 
on the fourth day after birth, and in another instance the baby greatly wasted 
on the ninth day. its skin lying in folds, the milk placed in its mouth running 
out from inability to swallow ; in fine, death impending. The physician and 
nurse could not believe that the mother had an insufficient supply of milk, 
but on applying the breast-pump not more than half a dozen drops of thin 
milk could be obtained. A wet-nurse was promptly procured, but death of 
the infant occurred in a few hours. It is not improbable that the breast-milk, 
insufficient from the first, became more scanty from the extreme grief, loss of 
sleep and appetite of the mother. An insufficient secretion of milk with its 
disastrous consequences to the new-born in well-to-do families, anxious and 
pecuniarily able to provide everything needed for the comfort and well-being 
of their offspring, is still more common among the poor in tenement-houses, 
and is most common when the mothers are insufficiently fed and are obliged 
to work for a livelihood, which often necessitates absence from home and 
separation from the infant. Insufficient food may render the milk more 
watery, as has already been stated, or it may cause diminution in its quantity. 
The mother thus situated is pallid. She is subject to palpitation and attacks 
of faintness. Her condition, indeed, is that of anaemia. Working women 
have scantiness of milk, not only in consequence of hardships, but also 
because, as stated above, they are usually separated for hours from their 
infants. Age is also a cause of scantiness of milk. Mothers at the age of 
forty years ordinarily furnish less milk than between twenty and thirty. 
Those who have not borne children till late in life, and whose mammary 
glands have therefore long been inactive, have less milk than those who com- 
mence bearing children at the usual period. 

Routh speaks of hyperemia as a cause of defective lactation. " This is 
a variety," says he, " which I have chiefly observed among hired wet-nurses 

selected from the poorer classes and admitted into wealthier families 

When feeding at the expense of a master or mistress the amount they devour 
surpasses all moderate imagination. They, in fact, gormandize. If in such 
instances a wet-nurse be given all she asks for, she will be found often to 
to eat quite as much as any two men with large appetites ; and as a result she 
becomes gross, turgid, often covered with blotches or pimples, and generally 
too plethoric to fulfil the duties of her position. The plethora, as first 
induced, is of the sthenic variety, but it soon assumes an asthenic character, 
and as the immediate result the breast no longer secretes its quantity of 
milk. There may be good milk secreted, but it is in small quantity, and this 
quantity diminishes daily. The breast may also enlarge, but it is from a 
deposition of fatty tissue in and about it, as in other parts of the body. The 
veins on the surface become less apparent — always a bad feature in a suckling 
breast — till finally the flow of milk ceases altogether." But the gormandiz- 
ing habit referred to by Dr. Routh does not often in this country cause dimi- 
nution or impair the quality of the milk, provided that the nursling is faith- 
fully and properly applied to the breast. By frequent suckling the glands 
continue actively secreting. 

Atrophy of the breast from the employment of iodine or from long disuse 
is also a cause of insufficiency of milk. 

It is so necessary for the health and development of the infant that the 
milk should be in proper quantity as well as quality that it is best in a work 
of this kind to consider the treatment of insufficient secretion, and. on the 
other hand, of excessive secretion and loss of milk, or galactorrhea ; and first 
of insufficient or scanty secretion. 



40 INFANCY AND CHILDHOOD. 

The most efficient mode of increasing the lacteal secretion is that which 
is also natural — namely, suction from the nipple. There are many cases on 
record in which this has produced the flow of milk in women who have never 
borne children, and even in men. Baudelocque mentions the case of a girl 
eight years old who suckled her brother for a month, and cases at the opposite 
extreme of life have been reported — one of a women of seventy years who 
wet-nursed a grandchild twenty years after her last confinement. 

The following case, which was under my observation, is interesting in this 

connection : Lizzie S was confined with her first child on May 30, 1876. 

When the baby was a few days old, and before she had left the bed, she had 
inflammatory symptoms which proved to be due to pelvic cellulitis. Its 
course was tedious ; her milk diminished, and its secretion soon ceased. On 
or about the 1st of August she began to sit up, and on August 11th she 
was admitted into the Sixty-first street branch of the Infant Asylum, pale 
and wasted, but with returning appetite. She had no mammary secretion for 
eleven weeks, and her breasts were small and flabby. She had two fistulous 
openings, one vaginal and the other low down in the back, near the lower 
end of the sacrum or the coccyx. The baby was in a fair condition, having 
been wet-nursed by other women. Experiences in this and other institutions 
show that infants having breast-milk do far better and are much more likely 
to live than those without breast-milk, and the mother was therefore advised 
by one of the managers — himself a physician — to suckle her baby, although 
there was not a drop of milk in her breast and nursing had been suspended 
eleven weeks. To the surprise of the mother and of the nurses in the 
house — to whom the procedure seemed very ridiculous — milk began to appear 
in a few days. The mother left the institution October 8th, but before her 
departure she was able to furnish perhaps two-thirds the quantity of milk 
which her infant required. This case affords practical illustration of the fact 
that frequent suckling is the most efficient galactagogue. Mothers sometimes, 
having little breast-milk, suckle their babies at long intervals, and finally, 
discouraged at the unproductive state of their breasts, resort to weaning, 
when by patience and more frequent use of their breasts they might become 
good wet-nurses. In the cities and during the summer season, in which 
breast-milk is so much required, the history of cases like the above, and the 
more remarkable cases in which men and grandparents have had secretion of 
milk and have suckled infants, should induce the physician to withhold his 
consent to premature weaning, which the disheartened mother is apt to sug- 
gest, unless indeed he perceives other reasons for weaning apart from scanti- 
ness of milk. 

Travellers among barbarous nations or tribes have often observed these 
cases of unnatural lactation. Humboldt saw a man thirty-two years old 
who gave the breast to his child for five months, and Captain Franklin in 
the Arctic regions met a similar case. Dr. Livingstone in his African trav- 
els says that he has examined several cases in which a grandchild has been 
suckled by a grandmother, and equally remarkable instances of wet-nursing 
occur among the negroes of the Southern and Middle States. Professor 
Hall presented to his class in Baltimore a male negro, fifty-five years old, 
who wet-nursed all the children of his mistress. In these cases of abnormal 
lactation, so far as we have accurate records of them, it is ascertained that 
the breasts were torpid, and even sometimes, as in old people, atrophied, till 
the nursing commenced. Titillation or pressing of the nipple caused an afflux 
of blood to the gland and developed its functional activity, so that milk was 
produced for the sustenance of the nursling. Therefore, in case of scanty 
secretion of milk the mother may increase the quantity by applying the 
infant often to the breast. If, dissatisfied with the small amount of nutri- 



RULES IN REGARD TO LACTATION. 41 

ment which it receives, it refuse to make the necessary suction, any other 
mode of gentle traction or pressure may be employed in addition. The occa- 
sional employment of another infant or a pup, milking the breast with the 
thumb and lingers, or the gentle suction of a breast-pump aids in stimulat- 
ing the secretion. Forcible rubbing or traction of the breast defeats the pur- 
pose for which it is employed. It produces too much irritation and tender- 
ness. The best mode of stimulation is by nursing, as it is the natural mode, 
and the effect of the infant at the breast upon the maternal instincts aids in 
promoting the secretion. 

Another mode of increasing the functional activity of the mammary glands 
is by the electrical current. The fact is established by physiological experi- 
ments that glandular organs can be made to secrete more actively by the 
stimulus of electricity, and, accordingly, this agent has been successfully 
employed to promote the secretion of milk. In Routh's Infant Feeding 
several cases are related which show the beneficial effects of this agent 
(page 1-19 et seq.~). Among them are six reported by Dr. Skinner of Liver- 
pool. In all these one or two applications of the electrical current sufficed 
to restore the secretion. The following is Dr. Skinner's mode of employing 
this treatment : 

" 1. Direct. — Both poles must terminate in cylinders, with sponges 
moistened in tepid water. The positive pole is pressed deep into the axilla, 
while the negative is lightly applied to the nipple and the areola, the current 
being no stronger than is agreeable to the patient's feelings. The poles are 
kept in this position for about two minutes. 

" 2. Intra mammary. — The poles are to be, as it were, imbedded in the 
mamma and moved about, raising and depressing both poles at once in and 
around the organ for the space of another two minutes. The same is to be 
done to both breasts daily until the secretion is properly established. Hith- 
erto one or two sittings have always sufficed in my hands" (Communication 
of Dr. Skinner to Dr. Routli). 

In all cases of scanty secretion of milk the regimen of the mother is a 
matter of importance. Personal and domiciliary cleanliness is essential for 
successful wet-nursing. A certain amount of exercise in the open air is con- 
ducive to the health of the mother and to the secretion of abundant and 
healthy milk. A case is related to show the effect of fresh air and out-door 
exercise on the lacteal secretion. A lady of cleanly habits, living in London, 
had a very scanty supply of milk. She removed to the pure air of the sea- 
shore, and immediately the quantity became abundant and continued so for 
months. Such cases are not infrequent. A mode of life that contributes to 
the general health of the mother will not fail to augment the quantity of her 
milk if it be scanty, and to improve its quality. 

Much has been written in reference to the diet of women who suckle. It 
is a popular belief that certain articles of food promote the secretion of milk 
much more than other articles, though equally nutritious. No doubt writers 
have erred in recommending exclusively this or that kind of food as most likely 
to produce milk. The exact kind of food which is preferable in a certain case 
depends partly on the physique of the individual and partly on the character 
of the food to which she has been accustomed. A mixed diet contributes 
most to the sustenance of the mother and to an abundant secretion of milk. 

There are certain kinds of food which do appear to have a galactagogue 
effect with most wet-nurses. Oatmeal gruel is one of these. Wet-nurses 
often remark, after taking a bowl of this, that they feel the flow of milk. 
Cow's milk with some has a similar effect. Porter or ale. taken once or twice 
a day, also promotes the secretion of milk, especially in those who have poor 
appetites and whose systems are somewhat reduced. 



42 INFANCY AND CHILDHOOD. 

A great variety of medicines have been used for their supposed galacta- 
gogue effect. Medicines which improve the general health are no doubt 
sometimes useful for this purpose, such as the vegetable and ferruginous 
tonics and, perhaps, cod-liver oil. But there are other medicines which it is 
claimed have a specific effect on the mammary gland, promoting its secretion. 
Lettuce, wintergreen, fennel, the broom tops (scoparius), and marshmallow 
have been used for this purpose. There can be no doubt that the aromatic 
stimulants, as fennel, anise, and carraway seed, given in soups, sometimes 
stimulate the lacteal secretion. Another medicine which has been recom- 
mended to the profession as a galactagogue is castor oil and the plant from 
which it is derived. Recently a medicine designated nutrolactis, prepared 
from the galega or goat's rue, which the laity in the country where it grows 
believe promotes the mammary secretion, has been employed in two of the 
New York maternity services, and confidence in it for this purpose has been 
fully established by those who have witnessed its effect. The dose is one 
tablespoonful three times daily. 



CHAPTER Y. 

SELECTION OF A WET-NURSE. 

In the cities cases are frequent in which mothers, with all possible care 
or endeavor, find themselves unable to suckle their infants. Their health is 
too poor or the milk possesses the properties of colostrum, or it is no longer 
secreted on account of nervous excitement or exhaustion or inflammation of 
the breasts. The number of such cases in the city would surprise physicians 
who are familiar only with the healthy and robust mothers of the country. 
The infant thus deprived of the mother's milk should, if practicable, be fur- 
nished with a wet-nurse. 

The selection of a wet-nurse often devolves upon the physician, and is a 
duty of great responsibility. We have stated elsewhere why it is better to 
select one between the ages of twenty and thirty years. Those who have 
previously suckled and had charge of infants are obviously more competent 
to serve as wet-nurses than are primiparas. The milk of a wet-nurse whose 
infant is under the age of six months will ordinarily agree with a new-born 
infant. If above that age it sometimes agrees, but often does not. 

The most difficult and responsible task imposed on the physician in the 
selection of a nurse is to ascertain the exact condition of her health and the 
quantity and quality of her milk. Constitutional syphilis is common in the 
class of women who present themselves for wet-nursing ; it is often latent or 
its symptoms are easily concealed, and it is communicable by lactation. The 
virus may be received by the infant from fissures or excoriations of the nip- 
ple. The nursling tainted by syphilis may, on the other hand, communicate 
the disease to the nurse through the same source. It is not fully ascertained 
whether the syphilitic virus may be conveyed to the infant by the milk. But 
the cases which have accumulated in the records of medicine are numerous in 
which infants born of healthy parents have contracted syphilis from the 
breasts of diseased nurses, (See article Syphilis.) These infants have some- 
times led a short and miserable existence, and have occasionally increased the 
misery of the household by imparting the disease to others. The duty is 
therefore imperative on the part of the physician to examine carefully the 



SELECTION OF A WET-NURSE. 43 

wet -nurse in reference to any evidences of the syphilitic taint. Acquainted 
with the symptoms of syphilis, he may usually, by shrewd questioning and 
by careful examination of the present appearance and condition of the 
woman, ascertain with considerable certainty whether her system has ever 
been infected. References should also be obtained and consulted, and, 
if practicable, the physician who has attended her be communicated with. 
It is safer to employ a wet-nurse two months after her confinement than 
previously, for if she have the syphilitic taint it will by this time show itself 
in the innutrition, coryza, and anal sores of her infant. 

There are also, among the women who present themselves for wet-nursing 
in the cities, many of a scrofulous habit and many who possess an hereditary 
tendency to tuberculosis, if indeed they do not already have the incipient 
disease. Such applicants should be rejected on account of the poverty of 
their milk and the probability that they will not be able to endure the debil- 
itating effect of wet-nursing. 

The milk should be examined in order to ascertain its richness and quan- 
tity and whether it contain colostrum. If there be colostrum after the eighth 
day, it is probable that there is some fault in the health or digestion of the 
wet-nurse, and that her milk may disagree with the infant. It is not neces- 
sary that the breast should be large in order to furnish a sufficient quantity 
of milk, since, as has been already stated, in some the secretory function is 
active during the time of each nursing, so that, although the breasts are of 
moderate size, a sufficient amount of milk is furnished. 

By examination of the milk its degree of richness can be readily ascer- 
tained. A quantity of it should be placed in a test-tube, and the cream 
which rises to the top indicates, approximately, the character of the milk. 
Good milk furnishes 3 per cent, of cream, and the casein and sugar usually 
correspond in quantity with the cream. An instrument has been invented, 
called the lactometer, by which the exact amount of the cream can be ascer- 
tained. It is simply a tube graded into one hundred divisions. It is placed 
upright and filled with milk, and the number of divisions occupied by the 
cream indicates its proportion in one hundred parts. 

Examination of the milk by the microscope not only enables us to deter- 
mine whether there are abnormal corpuscular or granular elements, but also 
its richness. It should be examined before the cream has separated. Oil- 
globules of small size and few indicate poverty of the milk ; very large oil- 
globules are said to indicate milk which is liable to be indigestible, especially 
in feeble infants. Such are the free globules of the colostrum. Numer- 
ous oil-globules of medium size indicate nutritious milk. In examining the 
milk by the microscope or otherwise in order to determine its richness, the 
important fact should be borne in mind that milk removed from the breast 
at short intervals is richer or more concentrated than that removed at long 
intervals, as we have stated elsewhere. A larger percentage of water is 
present if the interval be four hours than if it be two hours. Another im- 
portant fact which should be borne in mind in testing the milk is that that 
first drawn from the breast is more watery, or not so rich, as that last re- 
moved or the stripping, as is seen by the following analysis, made by Har- 
rington and published by Rotch in his interesting paper on infant feeding in 
the Cyclopaedia of Diseases of Children : 

Fat. £$£, Water. Ash. 

Foremilk 3.88 

Middle milk. . . .6.74 
Strippings 8.12 



13.34 


86.66 


0.85 


15.40 


84.60 


0.81 


17.13 


82.87 


0.82 



44 INFANCY AND CHILDHOOD. 

The increase in the solid constituents of the milk near the close of a 
nursing is said to be chiefly of fat, but partly of the albuminoids. It is 
evident, therefore, that the milk obtained from a breast that is emptied at 
short intervals is richer than that obtained when the breast is drawn at long 
intervals. 

Rotch publishes the following analysis made by Harrington, in which this 

fact is clearly shown : 

Milk drawn at two Milk drawn at twelve 

hours' interval. hours' interval. 

Total solids . . . .15.32 10.14 

Water ■ 84.68 89.86 

100.00 100.00 

Vogel in 1850 made the discovery of vibriones in human milk. The fact 
is established that these animalcules may be generated in the milk within the 
breast, though such cases are not frequent. Dr. Gibb describes a case which 
he met {Ranking s Abstract, vol. xxxiv.) : An infant seven weeks old, wet- 
nursed by its mother, who had the appearance of perfect health, was, never- 
theless, ill-nourished and emaciated. It had no diarrhoea or other apparent 
disease, and the milk was therefore examined. Yibriones were discovered in 
the milk immediately after it was obtained from the breast. The milk had 
the usual amount of cream, and seemed to the naked eye of good quality. 
According to Dr. Gibb, two genera of microscopic organisms occur in the 
milk — namely, vibriones and monads. It is believed that the monads occur 
in consequence of fermentation of the sugar and the production of lactic acid. 
Vogel also attributed the production of the vibriones to fermentation occur- 
ring in consequence of heat and congestion of the breast connected with sexual 
excitement. This explanation is probably not correct, because vibriones some- 
times occur when there is no unusual heat of breast and no evidence of fer- 
mentation. The fact that such organisms may be found in milk which seems 
of good quality to the naked eye affords additional proof of the usefulness of 
the microscope in the selection of a wet-nurse. 

Many wet-nurses have a return of the menses as early as the fourth or 
fifth month after delivery. The re-establishment of this function in some 
women impairs the quality of the milk, so as to render it less nutritious, and 
perhaps less digestible, during the time of the catamenial flow, as we have 
stated in a preceding paragraph. In the selection of a wet-nurse, then, pref- 
erence should be given to one who does not have the periodical sickness ; but 
if she be already employed and give satisfaction, the reappearance of the cata- 
menia does not indicate the need of the change of nurse, unless the digestion 
of the infant be disordered or its nutrition be impaired. 

In the selection of a wet-nurse attention should also be given to her mental 
and moral traits. Cheerfulness, affection, veracity, and a proper appreciation 
of the responsibility of her situation enhance greatly the value of a wet-nurse. 
Not less important are habits of temperance and cleanliness. I could cite 
cases of the most melancholy results from the absence of these traits. In one 
case idiocy resulted from an infant falling upon the pavement from the arms 
of a reckless or intemperate wet-nurse. 

In most cases the mode of examination indicated above suffices to show 
the character of a wet-nurse, so far as her health and milk are concerned. It 
should be borne in mind, however, that the microscope does not always reveal 
deleterious properties in the milk. Elements which are in a state of solution, 
and are invisible, may occur in excess, so as to impair the quality of the milk 
and render it indigestible. The following case, in which the saline ingredients 
seem to have been in excess, is related by Dr. Hartman (British and Foreign 
Medical Review, vol. xii.) : " An infant whose mother was in good health and 



COURSE OF WET-NURSING— WEANING. 45 

had borne several children exhibited a healthy appearance for the first five 
weeks after birth. The alvine evacuations then became copious, fluid, and 
discolored, and the child lost flesh and strength. After the usual remedies 
had been vainly administered for a fortnight, the mother remarked that the 
child did not take the right breast willingly, and so much did the unwilling- 
ness increase that at length the mere application of the nipple to the child's 
lips occasioned loud crying. On examination it was found that the milk of 
the right breast had a distinctly saline taste, whereas the milk of the opposite 
breast was of the ordinary sweetness ; no difference of consistence or color 
was discoverable. From that time the child was only allowed to nurse the 
left breast, and in a few days all diarrhoea and sickliness of appearance 
vanished. "' In this case there was no appreciable disease of the breast, 
although its secretion was perverted. The deleterious character of the milk 
was discovered, not by any change in its appearance, but by the taste. 

It is obviously very necessary, before recommending a wet-nurse, to ascer- 
tain whether she will probably furnish sufficient milk ; for, however excellent 
she may otherwise be, if she do not satisfy the wants of the infant she obvi- 
ously should not be employed. If the infant of the nurse be well nourished, 
and if it seem satisfied after nursing ten or fifteen minutes, she probably has 
sufficient milk. The more exact method of weighing the infant before and 
after it nurses, and observing whether the difference corresponds with that 
given in Chapter VII., enables us to determine more accurately the capabil- 
ities of the wet-nurse. 



CHAPTER VI. 

COUKSE OF WET-NUKSING— WEANING. 

After the birth of the infant the mother needs rest a few hours — four or 
five or a little longer in tedious and exhaustive cases — and then it should be 
applied to the breast. There is frequently a little milk at this time, and the 
act of nursing promotes the secretion and increases the quantity. The full 
secretion is not, however, established before the third day, and, though the 
infant be applied to the breast often, it obtains but little milk. Infants are 
so constituted that they require but little food until it is naturally provided 
for them, and the common practice of feeding them to repletion with various 
sweetened mixtures almost as soon as life begins, because they obtain little 
breast-milk, is to be deprecated. Filling their stomachs in this way has a 
tendency to prevent their drawing upon the nipples with the avidity which 
is required to stimulate a free flow of milk. Besides, as I have many times 
observed, indigestion, diarrhoea, and sprue are common results of this inju- 
dicious feeding. If, therefore, the infant be applied to the breast every second 
hour when the mother is awake till the third day, and be fed nothing besides. 
there need be no anxiety as regards its nutrition. If on the third day the 
breasts do not begin to fill and the secretion be delayed, a little fresh Pas- 
teurized cow's milk, diluted with double its quantity of warm water, and 
slightly sweetened, should be given every fourth hour, but should be with- 
held as soon as the flow of milk occurs. 

Infants under the age of one month should take the breast about every 
hour and a half by day and at longer intervals by night, or about twelve 
times in twenty-four hours, for the stomach of the new-born holds but little. 
and therefore receives but little at each nursing, and its digestion is active. 



46 INFANCY AND CHILDHOOD. 

The interval should be longer at night than in the day-time, so as to allow 
the mother more sleep. In the second month and subsequently the interval 
should be about two hours. 

The infant should be habituated to nursing at regular intervals, and when 
it is, it will ordinarily awaken at about the proper time. The practice on the 
part of the mother of applying the babe to the breast whenever it frets and 
as a means of quieting it, although it have but just nursed, is pernicious 
and should be forbidden. Giving the stomach no time to rest or filling it to 
repletion tends to produce indigestion and diarrhoea and to increase its fret- 
fulness. The cause of the fretfulness should be sought for, that the proper 
measures may be applied. Frequently it is due to insufficient breast-milk, 
and more or less supplementary feeding may be required. 

While regularity in nursing is required, still, as M. Donne has said, 
mathematical exactness in this matter would be ridiculous. Quiet natural 
sleep of a well-nourished infant should not be interrupted in order to give it 
the breast, unless the sleep be unusually protracted. It will usually awaken 
when the system requires more nutriment. Ill-nourished infants often sleep 
but little, making known their want by crying and fretfulness, until they 
become wasted and prostrated, when they are drowsy in consequence of pas- 
sive congestion of the brain. This drowsiness is evidently a pathological 
symptom. It shows the need of increased nutrition. It is due to scantiness 
of milk or milk of poor quality, and the infant should be aroused frequently 
for the purpose of giving it nutriment or even stimulants. The breast-milk 
is sufficient for its nutrition till the age of six or eight months, provided that 
it is abundant and of good quality. Therefore, if the mother be strong and 
experience no exhaustion, no other nutriment need be given till that age. 

Many mothers, however, by the third or fourth month of wet-nursing find 
that they have not sufficient milk to meet the wants of the infant. The con- 
stant drain upon their systems sensibly impairs their health. In such cases 
it is proper to commence with a little feeding from the spoon or bottle, and 
increase the quantity given as the infant grows older. Great care is, how- 
ever, requisite in the preparation of food for so young an infant, whose 
digestive organs are still feeble and easily deranged. In the county, where 
diarrhoeal affections and the so-called gastric derangements are not frequent, 
the danger from artificial feeding is less than in the city, and in the cool 
months in the city the danger is less than in the summer season. Infants of 
the city between the months of May and October have a strong predisposition 
to diarrhoeal attacks, the result of antihygienic influences which surround 
them. Errors of diet in their case readily provoke disease or derangement 
of the digestive organs, often of a severe and dangerous form. Moreover, 
experience has shown that artificial feeding during the period when nature 
designed that they should be nourished at the breast very commonly produces 
in the hot months more or less vomiting and diarrhoea, followed by emacia- 
tion and other evidences of malnutrition. Therefore an exception must be 
made in case of the city infant as regards the commencement of artificial 
feeding. If it be under the age of one year, it should be nourished exclu- 
sively, or almost exclusively, at the breast during the hot months when prac- 
ticable, even if the mother suffers somewhat in her health from the constant 
drain upon her system. It should, however, receive the amount of nutriment 
which it requires, and, if there be not sufficient breast-milk, it will be neces- 
sary to supply the deficiency by artificial feeding. The reader is referred to 
Chapter VIII. for facts relating to the subject of artificial feeding. 

Weaning ought to take place, as a rule, between the ages of ten and 
twelve months. It is well, if the mother's health be good and her milk 
sufficient, to defer weaning till the canine teeth appear. The infant, then 



Q UANTITY OF FOOD BEQ UIRED IN INFANCY AND CHILDHOOD. 47 

possessing sixteen teeth, is able to masticate the softer kinds of solid food. 
Weaning should be gradual. Mothers often speak of weaning on a certain 
day. They have given but little artificial food and have suckled at regular 
intervals, till at a fixed time they have denied the breast altogether. This 
abrupt change of diet should be discouraged. It should only be recom- 
mended under peculiar circumstances. It is likely to derange the digestive 
organs, and it causes fretfulness and sleeplessness on the part of the infant 
for a week or more. Weaning should commence by feeding with a spoon a 
little oftener through the day, and nursing less, and by discontinuing the 
practice of suckling at night. The infant tolerates this gradual change of 
diet, while it rebels against sudden weaning, and by its fretfulness increases 
greatly the care and trouble of the mother. Nurslings in the city should 
not be weaned in warm weather nor within a month immediately preceding 
it. If the mother's health fail or her milk become deficient in the summer 
months, so that she cannot continue suckling, a wet-nurse should be employed, 
or the infant should be sent to some rural locality and weaned there. Wean- 
ing in the city in hot weather should, if practicable, be avoided on account 
of the liability to the summer diarrhoea produced by change of diet, although 
I believe there is less danger from this than formerly, since we now under- 
stand better how to feed infants. 



CHAPTER VII. 
QUANTITY OF FOOD REQUIRED IN INFANCY AND CHILDHOOD. 

Infantile Feeding. 

Over-feeding. — More than half a century has elapsed since the most dis- 
tinguished New England physician of his day, Dr. James Jackson of Boston, 
wrote in his Letters to a Young Physician that a certain ailment of the diges- 
tive system of infants had often puzzled him when a young practitioner. It 
was characterized by the occurrence of green and unhealthy stools, showing 
imperfect digestion. The stools contained an unusual amount of mucus, and 
were passed more frequently than the normal stools of a healthy infant. 
After observing many infants thus affected, and ascertaining the manner and 
frequency of their feeding, the truth gradually dawned upon him that their 
unhealthy evacuations were due to over-feeding. By diminishing the amount 
of nutriment given and lengthening the intervals between the feedings these 
infants were soon cured. 

Suction by the lips of the infant seems to be to a great extent automatic, 
so that if its mother or wet-nurse have a copious supply of milk, it is liable 
to over-nurse, or, if it be bottle-fed, is liable to take more from the bottle 
than it requires for its nutrition. Some infants if over-fed regurgitate the 
surplus food, but others do not, and the portion which is not digested under- 
goes fermentation and acts as an irritant to the stomach and intestines. 
Acids, as the butyric and lactic, and gases which distend the stomach and 
intestines and cause colicky pains, form from the fermentation. An infant 
thus suffering from overtaxed digestion, and from the presence of irritating- 
acids and gases in the stomach and intestines, is usually fretful and its sleep 
is disturbed and broken. The cause of its restlessness is often misunder- 
stood by the mother, who thinks it may be due to insufficient nutriment, and 



48 IXFAXCY AND CHILDHOOD. 

accordingly it is applied more frequently to the breast, or, if it be bottle-fed, 
it is given the bottle more frequently. I have seen not a few over-fed infants 
who on account of their fretfulness were applied to the breast at intervals of 
a few minutes, so that the health of their mothers was impaired by the lack 
of sleep and the drain upon their systems ; and the infants, on account of 
too frequent nursing, had indigestion, and occasionally gastro-intestinal 
catarrh. Moreover, milk drawn too frequently from the breast usually 
contains an excess of the solids, so that it is digested with more difficulty 
than when it is drawn at the proper intervals, as I have elsewhere stated. 
For this reason also too frequent application of infants to the breast is likely 
to cause indigestion and gastro-intestinal derangements. 

Cases might be related to substantiate these statements. Thus in Decem- 
ber last I attended an infant of four months that had been very fretful and 
with insufficient sleep for weeks. The wet-nurse who had charge of it had 
apparently the proper requisites, such as health, youth, robustness, and well- 
developed breasts, which seemed to furnish sufficient milk and of good qual- 
ity. But the infant, though fairly nourished, had so little sleep and was so 
fretful, crying so much during the night as well as day, that the whole house- 
hold was deprived of the needed rest. The nature of the baby's ailment 
was soon detected, for its stools presented appearances indicative of indiges- 
tion and intestinal catarrh. They contained numerous rounded, whitish 
masses, apparently of casein mixed with mucus and thin fecal matter. 
Pepsin preparations with bismuth were at first employed, without any 
marked result, but improvement began at once when the infant, instead of 
being frequently applied to the breast, as had been the practice, was allowed 
to take it only every third hour, and was fed nothing in the interval. It had 
been over-fed, and the remedy more effectual than the medicines employed 
was the simple one of its less frequent application to the breast. Over-feed- 
ing is, I think, more common with bottle-fed infants than with those nour- 
ished at the breast. 

Insufficient Nutriment. — We have alluded in a preceding page to 
insufficient feeding of the newly-born, but older infants, both wet-nursed 
and bottle-fed, frequently do not obtain sufficient nutriment. In families of 
the city poor nursing mothers often have scanty diet and are over-worked, and 
the milk which they furnish to their nurslings under such circumstances is 
liable to be watery and insufficient. Sometimes infants, when they have 
reached an age at which the breast-milk is inadequate and additional food 
is urgently needed, are nevertheless denied this by their mothers. Even 
mothers who are apparently robust, and give the breast at proper intervals, 
often have insufficient milk, so that their infants do not thrive, and they are 
ignorant of the cause. MM. Vernois and Becquerel, on careful examination 
of 89 infants wet-nursed by women apparently in good health, ascertained 
that 15 were insufficiently nourished. An infant that obtains sufficient breast- 
milk draws the breast quietly and continuously twelve or fifteen minutes, 
when it releases its hold of the nipple and probably falls into a quiet sleep, 
having a satisfied aspect. If the breast-milk is scanty and insufficient, the 
baby is fretful when it nurses, frequently lets go of the nipple, and does not 
have the quiet sleep of the satisfied infant. If its mouth be inspected when 
it is nursing, it will be found to contain but little milk. But if the supply 
of breast-milk be abundant, it will appear in quantity between the lips and 
in the mouth of the infant during the nursing. 

Again, many bottle-fed infants are allowed sufficient food, but it is not 
adapted to their age, and is digested with difficulty, so that the nutriment 
which they derive from it is insufficient. Much has been said and written 
upon the practice common in tenement-houses of giving farinaceous food to 



QUANTITY OF FOOD REQ UIRED IN INFANCY AND CHILDHOOD. 49 

infants under the age of three months, when the saliva, which is the chief 
agent that digests starch, is scanty and insufficient for its digestion. In the 
feeding of older children in families of the laboring class we know how fre- 
quently food is employed that is unsuitable to the age — that acts as an irri- 
tant to the stomach and intestines, producing attacks of vomiting and diar- 
rhoea. The portion of such food that is digested and which serves for 
nutrition is insufficient, while the undigested part acts as an irritant. Infants 
that receive such unsuitable diet really suffer from lack of food, although its 
bulk may be sufficient. They are hungry from the lack of proper nutri- 
ment, and are consequently fretful. They digest and assimilate so small a 
part of this unsuitable diet that they lose flesh and have the usual symptoms 
of innutrition. 

It is evident from this survey of what actually occurs in the feeding of 
infants that, while it is of the utmost importance that food should be of the 
proper kind according to the age and properly prepared, it is also equally 
necessary for their successful alimentation that they be fed at proper inter- 
vals and with the proper amount of food. 

A few years since Drs. Chadbourne, Parker, and myself made observa- 
tions in the New York Infant Asylum and New York Foundling Asylum in 
order to determine how much food children require at different ages. Those 
selected for observation were well nourished, and they were accurately weighed 
before and after each nursing or feeding. Eleven infants under the age of 
three weeks, who took the breast, with three exceptions, twelve times in the 
twenty-four hours, were found to take in the average 12.55 ounces of the 
breast-milk in the day and night, as is seen by the following table : 



Table I.- 


—Newly 


■horn Infants (those under the Age of Three 


Weeks) . 




! 




Milk nursec 


in 24 hours. 


Xo. 


Name. 


Age. 


Number of 
nursings. 


Quantity in 
weight. 


Quantity in 
fluidounces. 










oz. dr. 




1 


J. F 


17 days. 


11 


10 h 


9.75 


2 


H. C. 


















16 " 


9 


13 5^ 


13.24 


3 


H. J. 


















19 " 


9 


10 3 


10.07 


4 


K. . . 


















5 " 


12 


22 7 


22.22 


5 


H. B. 


















6 " 


12 


15 5* 


15.25 


6 


W. F. 


















5 " 


12 


10 H 


9.88 


7 


K H. 


















14 " 


12 


17 3^ 


16.85 


8 


C. F. 


















5 " 


12 


5 4 


5.37 


9 


F. D. 


















7 " 


12 


14 4 


14.8 


10 


E. S. 


















6 " 


12 


8 1 


7.74 


11 


R. B. 


















3 weeks. 


12 


14 1 


13.68 



The observations in the second table relate to infants between the ages 
of one month and ten months, and, with one exception, between the ages of 
two months and ten months. It was found, that they received on the average 
23.79 fluidounces of bfeast-milk in twenty-four hours. The number of 
nursings in the day and night varied from seven to ten. Therefore those 
infants between the ages of one — or, more accurately, two — months and ten 
months, if they took the breast eight times in the twenty-four hours, required 
three ounces at each nursing; if twelve times, they required two ounces 
each time. 

According to these statistics, infants under the age of three weeks nour- 
4 



50 



INFANCY AND CHILDHOOD. 



ished at the breast and suckled twelve times in the twenty-four hours require 
only one ounce, or not more than one ounce and a drachm, at each nursing ; 
and the very small size of the stomach at this age shows, I think, that it 
cannot receive much more than this without distention. After the third 
week the amount required for healthy nutrition gradually increases. 





Table 


II. 




-Ages/ 


rom One Month to Ten Months. 












Milk nursed 


in 24 hours. 








Number of 






No. 


Name. 


Age. 


nursings. 


Quantity in 
weight. 


Quantity in 
fluidounces. 










oz. dr. 




1 


A. S 


6 months. 


8 


26 1* 


25.3 


2 


J. B. 




















4 " 


9 


38 J 


36.8 


3 


W. G. 




















3* " 


8 


24 2 


23.5 


4 


L. B. 




















7 " 


10 


27 3J 


26.6 


5 


W. L. 




















5* " 


11 


28 7 


28 


6 


J. C. 




















5 " 


10 


29 7 


29 


7 


A. W. 




















3* " 


8 


19 2 


18.6 


8 


F. Van 


B 


















2 m. 10 d. 


7 


24 4 


23.7 


9 


E. W. 




















6 months. 


10 


12 4J 


12.2 


10 


F. S. 




















3J " 


8 


26 7 


26.1 


11 


S. W. 




















4 " 


8 


23 5 


22.9 


12 


J. G. 




















9 " 


8 


24 1J 


23.4 


13 


B.J. 




















7 " 


8 


27 4 


26.6 


14 


T. C. 




















6 " 


10 


26 6£ 


26 


15 


A. R. 




















6 " 


10 


21 6 


21.1 


16 


C. H. 




















1 m. 5 d. 


8 


11 1* 


10.84 



According to my observations, infants in good health and well nourished 
do not all require or take the same amount of food. Some infants, like 
adults, need more food than others, but the following table indicates, I think, 
nearly the quantity required during the first twelve months of infancy, either 
of breast-milk, or of cow's milk prepared so as to resemble as closely as pos- 
sible breast-milk in consistence and nutritive properties. It will be observed 
that this table resembles closely that prepared by Professor Rotch of Har- 
vard University, and published in his instructive paper on infant feeding in 
the Cyclopaedia of the Diseases of Children : 



Table III.- 


-Deductions 


from 


the above Statistics. 




At each feeding. 


Number of 
daily feedings. 


Total 
daily quantity. 


During the first week 1 oz 


10 
10 

8 
8 
7 
6 
5 


10 oz. 


At the third week 1J oz 


15 " 


At the sixth week 2 oz 


16 " 


At the third month 3 oz 


24 " 


At the fourth month 4 oz 


28 " 


At the sixth month 6 oz 


36 " 


At the tenth to twelfth months 8 oz 


40 " 













QUANTITY OF FOOD REQUIRED IN INFANCY AND CHILDHOOD. 51 



Table IV. — Observations relating to the Diet during Twenty-four Hours of 
Twenty-eight Healthy Children between the Ages of Two and Three Years, 
with an Average Age of Two Years and Eight Months. 



Bread 


Breakfast. 


Butter 


Milk 


Meat . . 


Dinner. 


Potatoes 


Milk . . 


Milk . . 


Supper. 


Bread 


Butter 



Total amount. 


Average for each. 


6 lbs. 4 oz. 1 dr. 


3.5 


oz. 


13 oz. 5 dr. 


0.45 


oz. 


22 lbs. 14 oz. 2 dr. 


12.7 


fl. oz. 


8 lbs. oz. 5 dr. 


4.6 


oz. 


6 lbs. 13 oz. 7 dr. 


3.9 


oz. 


17 lbs. 9 oz. 7 dr. 


9.4 


fl. oz. 


19 lbs. 12 oz. 1 dr. 


10.5 


fl. oz. 


7 lbs. 1 oz. 2 dr. 


4.0 


oz. 


14 oz. 7 dr. 


0.53 


oz. 



DAILY AVERAGE FOR EACH CHILD. 

Bread 7.5 oz. avoir. 

Butter 0.98 oz. " 

Meat (beef) 4.6 oz. " 

Potatoes 3.9 oz. " 

Milk 32.6 fl. oz. 



Table V. — Observations upon Twelve Children between the Ages of Three and 
Six Years : Average Age, Four Years and Ten Months. 



Bread . . 


Breakfast. 


Butter 


Milk 


Beef . . . 


Dinner. 


Bread 


Hice 


Milk 


Butter 


Bread . . 


Supper. 


Butter 


Milk 



Total amount. 


Average for each, 


4 lbs. 6 oz. 3J dr. 
5 oz. 2 dr. 
280 fl. oz. 


5.86 oz. 

0.427 oz. 

23.3 fl. oz. 


9 lbs. 1 oz. 3 dr. 
1 lb. oz. 1 dr. 
9 lbs. 12 oz. 7 dr. 
112 fl. oz. 

2 oz. 2£ dr. 


12.1 oz. 

1.6 oz. 
13.0 oz. 

9.3 fl. oz. 


2 lbs. 4 oz. H dr. 
5 oz. 5£ dr. 
192 fl. oz. 


3.0 oz. 
16.0 fl. oz. 



DAILY AVERAGE FOR EACH CHILD. 



Milk 


. . 48.6 fl. oz. 


Beef 


12.1 oz. av 




13.0 07. 




10.3 oz. 


Butter 


1.08 oz. ' 



52 



INFANCY AND CHILDHOOD. 



Table VI. — Observations relating to the Diet of Twenty-four Children — 
Twelve Boys, Twelve Girls — between the Ages of Four Years and Ten 
Years : Average, Six Years and Ten Months. 



Bread 
Butter 
Milk 



Roast beef 
Potatoes . 
Bread . . 
Milk . . 
Butter . . 



Bread 

Milk 

Butter 



Breakfast. 



Dinner. 



Supper. 



Total amount. 



7 lbs. 13 oz. 
12 oz. 

348 fl. oz. 



3 dr. 

3^dr. 



18 lbs. 11 oz. dr. 
15 lbs. 8 oz. 3 dr. 
1 lb. 6 oz. J dr. 
192 fl. oz. 

U dr. 



6 lbs. 2 oz. 3* dr. 
381 fl. oz. 

11 oz. bh dr. 



Average for each. 



5.21 oz. 

0.51 oz. 

14.5 fl. oz. 



12.46 oz. 
10.30 oz. 

0.92 oz. 

8.0 fl. oz. 

0.012 oz. 



4.1 oz. 

16.0 fl. 

0.16 oz. 



DAILY AVERAGE FOR EACH CHILD. 

Roast beef - 12.46 oz. 

Bread 10.23 oz. 

Potatoes • 10.3 oz. 

Butter 0.99 oz. 

Milk 38.5 fl. oz. 

Compare the above observations with those of Professor Dalton, who 
estimates that a healthy adult taking active exercise requires, each day, 

Meat 16 oz. 

Bread 19 oz. 

Butter 3| oz. 

Water 52 oz., 



while one leading a sedentary life needs considerably less. 

It will be seen by the above tables that even more food appears to be 
needed during the period of childhood than in adult life. We would suppose 
this to be so without statistical evidence, for the active exercise and rapid and 
progressive growth of this period necessarily require a large amount of nutri- 
ment. Moreover, while adults do well with solid food and water, statistics 
show that the best diet for children who have passed beyond infancy is one 
of milk, with solid food. 

Although we are able, by observations, to determine the average amount 
of food required in twenty-four hours by children of various ages, we repeat 
that it would be wrong to prescribe a fixed amount for all children of a given 
age, for some need more than others. A child should never go hungry after 
a meal. In some of the best-conducted institutions of New York the chil- 
dren eat of plain food all that they desire at each meal, while in other insti- 
tutions the food at supper is limited, but is abundant at the other meals. As 
children go to bed so soon after supper, it is proper to have this meal light 
and of such food as is easily digested. 

The time required in the digestion of different foods has been investigated 
by Beaumont and Bichat, but their investigations relate to adults. The time 



ARTIFICIAL FEEDING. 53 

occupied in the gastric digestion of various foods has been determined in 
adult cases by inspecting the interior of the stomach through a gastric fistula. 
No such opportunity has ever occurred, so far as I am aware, of inspecting 
the process of digestion in the interior of the stomach either in infancy or 
childhood. But recently experiments have been made for the purpose of 
determining the time occupied in gastric digestion in infancy. The import- 
ance of such experiments is apparent, for if we know how soon after feeding 
gastric digestion is completed and the stomach emptied, we will know how fre- 
quent the feeding should be. According to H. Leo, in an infant a few weeks 
old one hour suffices for the stomach digestion of the milk which it receives, 
so that this organ is already empty one hour after the nursing, and in a con- 
dition to receive more milk. In older infants, who receive more milk, the 
milk is retained longer in this organ, one and a half hours being required for 
the stomach digestion of human milk, and two hours for the digestion of 
cow's milk (Berlin. Hin. Wochenschr., No. 49, 1888). Recently (1889), Dr. 
Max Einhorn of New York has investigated the stomach digestion of infants, 
using a Xelaton catheter No. 14 A, with which he withdrew the contents or 
determined the emptiness of the stomach. He ascertained that in the infant 
receiving human milk the stomach was empty two hours after the nursing, 
and probably in one and a half hours. After feeding with equal parts of 
cow's milk and barley-water, the stomach was practically empty at a little 
before the close of the second hour. After feeding with milk and water, 
equal parts, the stomach was empty in about one and a half hours. The 
digestibility of several of the proprietary foods which are most in use was 
also ascertained in a similar manner. A considerable amount of these foods 
was still in the stomach undergoing digestion two hours after they were 
administered. These interesting and instructive observations of Dr. Einhorn 
indicate the intervals required in feeding with milk and with other foods. 

It is seen that there is a general agreement in the result obtained by dif- 
ferent observers in regard to the amount of food required at each feeding, 
and the proper intervals between the feedings, during infancy as well as 
childhood. 



CHAPTER VIII. 

AETIFICAL FEEDING. 

Occasionally the mother is unable to suckle her infant, and a hired wet- 
nurse cannot be or is not obtained. Artificial feeding is then necessary. In 
the large cities this mode of alimentation for young infants should be dis- 
couraged, if human milk abundant and of good quality can be obtained, for 
it frequently ends in death, preceded by evidences of faulty nutrition. A 
considerable proportion of those nourished in this manner thrive during the 
cold months, but on the approach of the warm season they are the first to be 
affected with diarrhoea and other symptoms indicating derangement of the 
digestive function. In New York City a large proportion of the artificially- 
fed infants who enter the summer months die before the return of cool 



54 



INFANCY AND CHILDHOOD. 



weather, unless saved by removal to the country ; but the mortality of these 
infants has been in a measure reduced of late years by improvement in the 
mode of feeding and in the sanitary condition of the nursery. In the country 
and in small inland cities the results of artificial feeding are much more favor- 
able. In elevated farming sections, on account of the salubrity of the air 
and the facility with which milk, fresh and of the best quality, is obtained, 
artificial feeding is attended by much less risk than in the cities. 

Young infants, fed by the hand, obviously require food prepared so as to 
resemble as closely as possible human milk in its composition. Woman's 
milk in health is always alkaline. It has a specific gravity of 1031.7 ; cow's 
milk has a specific gravity of 1029. That of cows stabled and fed upon other 
fodder than hay or grass is decidedly acid. That from cows in the country 
with good pasturage is also slightly acid. In two dairies in Central New 
York a hundred miles apart, in midsummer, with an abundant pasturage, two 
competent persons whom I requested to make the examinations found the 
milk moderately acid immediately after the milking in all the cows. 

How to feed infants deprived of breast-milk is a very important problem. 
The following results of a large number of analyses of woman's and cow's 
milk, made by Konig and quoted by Leeds, and of several of the best-known 
and most-used preparations designed by their inventors to be substitutes for 
human milk, show how far these substitutes resemble the natural aliment in 
their chemical characters : 



Water . . 
Total solids . 
Fat . . 
Milk-sugar . 
Casein . . . 
Albumen . . 
Albuminoids 
Ash ... . 



Woman's milk. 



Mean. Minimum. Maximum, 



87.09 
12.91 
3.90 
6.04 
0.63 
1.31 
1.94 
0.49 



83.6 
9.10 
1.71 
4.11 
0.18 
0.39 
0.57 
0.14 



90.90 
16 31 
7.60 
7.80 
1.90 
2.35 
4.25 



Mean. 



87.41 
12.59 
3.66 
4.92 
3.01 
0.75 
3.76 
0.70 



Cow's milk. 



Minimum. 


Maximum. 


80.32 


91.50 


8.50 


19.68 


1.15 


7.09 


3.20 


5.67 


1.17 


7.40 


0.21 


5.04 


1.38 


12.44 


0.50 


0.87 



The following analyses of the foods for infants found in the shops, and 
which are in common use, were made by Leeds of the Stevens Institute : 

Farinaceous Foods. 





1. 
Blair's 
wheat 
food. 


2. 

Hubbell's 

wheat 

food. 


3. 

Imperial 
granum. 


4. 

Ridge's 
food. 


5. 

"ABC" 

Cereal 

milk. 


6. 

Robinson's 

patent 

barley. 


Water 

Fat 


9.85 
1.56 
1.75 
1.71 
64.80 
13.69 
7.16 
2.94 
1.06 


7 78 

0.41 

7.56 

4.87 

67.60 

14.29 

10.13 

Undet'm'd 

1.00 


5.49 
1.01 

Trace. 

Trace. 

78.93 
3.56 

10.51 
0.50 
1.16 


9.23 
0.63 
2.40 
2.20 
77.96 
5.19 
9.24 

0.60" 


9.33 

1.01 

4.60 

15.40 

58.42 

20.00 

11.08 

1.16 


10.10 
0.97 
3.08 
0.90 

77.76 
4.11 
5.13 
1.93 
1.93 


Grape-sugar 

Cane-sugar 

Starch 

Soluble carbohydrates • • 

Albuminoids 

Gum, cellulose, etc. . . . 
Ash 



ARTIFICIAL FEEDING. 



55 



Leibigs Foods. 



Water 

Fat 

Grape-sugar .... 

Cane-sugar 

Starch 

Soluble carbohydrates 
Albuminoids .... 
Gum, cellulose, etc. . 
Ash 



Mellin's. Hawley's 



5.00 

0.15 
44.69 

3.51 
None. 
85.44 

5.95 



1.89 



6.60 

0.61 
40.57 

3.44 
10.97 
76.54 

5.38 



1.50 





Keasbey 


Savory 


Horlick's 


and 


and 




Matti- 


Moore's 




son's. 




3.39 


27.95 


8.34 


0.08 


None. 


0.40 


34.99 


36.75 


20.41 


12.45 


7.58 


9.08 


None. 


None. 


36.36 


87.20 


71.50 


44.83 


6.71 


None. 


9.63 
0.44 


L28 


0.93 


0.89 



Baby sup 

No. 1. 




Milk Foods. 



Water 

Fat . . . 

Grape-sugar and milk-sugar 

Cane-sugar 

Starch 

Soluble carbohydrates . . 

Albuminoids 

Ash 



Nestle's. 



4.72 
1.91 

6.92 

32.93 

40.10 

44.88 

8.23 

1.59 



Anglo-Swiss. 



6.54 

2.72 
23.29 
21.40 
34.55 
46.43 
10.26 

1.20 



Gerber's. 



6.78 

2.21 

6.06 

30.50 

38.48 

44.76 

9.56 

1.21 



American-Swiss. 



5.68 

6.81 

5.78 

36.43 

30.85 

45.35 

10.54 

1.21 



It is seen by examination of the analyses of the above foods that all, 
except such as consist largely or wholly of cow's milk, differ widely from 
human milk in their composition, and although some of them — as the Liebig 
preparations, in which starch is converted into grape-sugar by the action of 
the diastase of malt — may aid in the nutrition and be useful as adjuncts to 
milk, physicians of experience and close observation agree that when breast- 
milk fails or is insufficient our main reliance for the successful nutrition of 
the infant must be on animal milk. 

Cow's milk, being readily obtained, is commonly used as a substitute for 
human milk, compared with which it contains less sugar, but more casein and 
salts. Its composition, however, varies considerably according to the food 
of the cow. The variations in the milk of the cow according to the nature 
of its food and other circumstances have been considered in a preceding- 
chapter. 

It is obvious from the above facts that the analyses of different specimens 
of cow's milk must differ greatly, and the same is true of the milk of the goat 
and ass, and probably of the ewe. In fact, different samples of the milk of 
the same animal may differ more from each other in their chemical character 
than the average milk of one animal from that of another. 

The milk of the goat and that of the ass have been recommended as food 
for infants in preference to cow's milk, on the ground that they more nearly 
resemble human milk. But the milk of neither the ass nor the goat, so far as its 
chemical character is concerned, would seem to possess any marked advantage 
over cow's milk. The ass's milk is procured with difficulty, and is seldom 
used. An objection to goat's milk is the unpleasant odor which it often pos- 
sesses, due to the presence of hircic acid. It is stated, however, by Parmen- 
tier, that this odor is only noticed in the milk of goats that have horns. An 



56 INFANCY AND CHILDHOOD. 

important advantage in the city in the use of goat's milk is that the animal 
can be kept at little expense, so that even poor families who are not able to 
purchase and feed a cow can generally possess a goat, from which fresh milk 
can be obtained at any time. Preference is to be given to goat's milk when 
fresh over cow's milk brought from the country, perhaps watered on the way, 
several hours old when received, and in commencing fermentation. But cow's 
milk of good quality and free from fermentative changes is probably not inferior 
to goat's milk as a food for infants, and from its abundance it must continue 
to be in common use for this purpose. 

In order to solve the problem of the feeding of infants deprived of the 
breast-milk, it will be well to recall to mind the part performed in the diges- 
tive function by the different secretions which digest food. 

1st. The saliva is alkaline in health. It converts starch into grape-sugar. 
It has no effect upon fat or the protein group. It is the secretion of the 
parotid, submaxillary, and sublingual glands, which in infants under the age 
of three months are very small, almost rudimentary. The power to convert 
starch into sugar possessed by saliva is due to a ferment which it contains 
called ptyalin. 

2d. The gastric juice is a thin, nearly transparent, and colorless fluid, acid 
from the presence of a little hydrochloric acid. It produces no change in 
starch, grape-sugar, or the fats, except that it dissolves the covering of the 
fat-cells. Its function is to convert the proteids into peptone, which is 
effected by its active principle, termed pepsin. 

3d. The bile is alkaline, and it neutralizes the acid product of gastric 
digestion. It has no effect on the proteids. It forms soaps with the fatty 
acids, and has a slight emulsifying action on fat. The soaps are said to pro- 
mote the emulsion of fat. Their emulsifying power is believed to be increased 
by admixture with the pancreatic secretion. Moreover, the absorption of oil 
is facilitated by the presence of bile upon the surface through which it passes. 

4th. The pancreatic juice appears to have the function of digesting what- 
ever alimentary substance has escaped digestion by the saliva, gastric juice, 
and bile. It is a clear, viscid liquid of alkaline reaction. It rapidly changes 
starch into grape-sugar. It converts proteids into peptones and emulsifies 
fats. While the gastric juice requires an acid medium for the performance 
of its digestive function, the pancreatic juice requires one that is alkaline. 
These important facts should be borne in mind, that such a mistake as pre- 
scribing pepsin with chalk mixture or the extractum pancreatis with dilute 
muriatic acid may be avoided. 

5th. The intestinal secretions are mainly from the crypts of Lieberkuhn, 
and their action in the digestive process is probably comparatively unimport- 
ant, but in some animals they have been found to digest starch. It will be 
observed that of all these secretions that which digests the largest number 
of nutritive principles is the pancreatic. It digests all those which are 
essential to the maintenance of life except fat, and it aids the bile in emul- 
sifying fat. 

It is seen from this brief review of the action of the digestive ferments 
that starch is digested in only a very small quantity by infants under the 
age of three months, and therefore that those foods which consist largely of 
starch afford but little nutriment at this age. The impropriety also of admin- 
istering for days large quantities of an alkali, as is frequently done, is appar- 
ent from the above statement in regard to the action of pepsin, since it may 
retard or prevent gastric digestion. 

It is very important for the welfare of the infant that the suckling mother 
or wet-nurse lead a quiet and regular life. I was much impressed by the ex- 
perience of a family that allowed their wet-nurse to go out of an evening. 



ARTIFICIAL FEEDISG. 57 

She spent the night in debauchery, and returned home in the morning ex- 
hausted and totally unfit for her duties as wet-nurse. Unfortunately, she was 
allowed to give the breast to the baby, which was immediately after seized 
with convulsions, ending in death. Occasionally the mother, though appar- 
ently in good general health, does not furnish milk that is suitable for the 
baby. The milk may seem abundant and may present the usual appearance, 
but it does not satisfy the nursling. It frets when applied to the breast, and 
afterward its sleep is insufficient and it does not thrive, so that it is necessary 
to employ a wet-nurse or wean the baby. The cause of this anomalous state 
of the mother's milk is probably an irregular and excited mode of life. I 
have observed it in mothers fond of society and late hours. 

An important fact, which we have stated in a foregoing page, and one 
that I find the laity are generally ignorant of, is that frequent suckling 
increases the quantity of the milk and its richness, so that if the interval be 
two hours between the drawing of the milk, it will be richer than if four 
hours intervene. If the mother says that she suckles her baby every six 
hours, and makes use of artificial food between — unfortunately, a not uncom- 
mon practice among the poor — we will find that the little milk obtained from 
her breast is thin like dish-water, and the infant obtains very little nutriment 
from it. If the mother be healthy and the flow of milk be normal, she can, 
I think, ordinarily nourish the infant entirely at the breast until it reaches 
the age of six months, after which some artificial food is usually required. 
Weaning should, as a rule, be at the age of ten or twelve months, but wean- 
ing in a city like Xew York, in which the summer diarrhoea is so prevalent 
and fatal, should never take place in the summer months. 

How to feed a baby deprived of the breast-milk during its first year is one 
of the most important problems which the physician is required to solve. It 
is evident that under such circumstances a food which most closely resembles 
human milk should be selected, and this is animal milk — in this country neces- 
sarily cow's milk. This, therefore, is properly selected as the most important 
dietetic article after weaning during the remainder of infancy and childhood. 
Indeed, cow's milk constitutes an important part of the food during the entire 
period of growth and development, but, unfortunately, it is a culture-medium 
for bacteria, and numerous epidemics of the communicable diseases have re- 
sulted from its use. It is evident that milk designed for the nursery should 
be as free as possible from microbes, prepared so as to be easily digested like 
human milk, and be sufficiently nutritious. 

As the result of many analyses Prof. Leeds, in addition to similar facts 
tabulated above, has arranged the following tables, showing the comparative 
composition of human and bovine milk. These tables indicate the changes 
which must be made in cow's milk so that it corresponds with mother's milk : 

Human Milk. Bovine Milk. 

ALKALINE. FEEBLY ACID. 

Sp. gravity 1.0313 . . 1.0297 

Bacteria absent. Always present . 

Fats 2 to 7 Average 4.13 3 to 6 .. Average 3.75 

Lactose 5.4 to 7.9 " 7.0 3.5 to 5.5 . . " 4.42 

Albuminoids 0.85 to 4.86 . . " 2.0 3 to 6 ... . " 3.76 

Ash. . . .0.13 to 0.37 . . " 0.2 0.6 to 0.9 . . lk 0.6S 

Diseases communicated by Cow's Milk. 

In the healthy state the mammary gland in woman and the udder of the 
cow contain no microbes, but, as a rule, cow's milk by the various manipu- 



58 INFANCY AND CHILDHOOD. 

lations which it undergoes before it reaches the nursery becomes infected by 
bacteria, as is seen by the above table prepared by Prof. Leeds, and not infre- 
quently by such as are pathogenic. The diseases of chief interest, on account 
of their severe and fatal nature, which are known to be communicated by 
infected cow's milk are tuberculosis, scarlet fever, diphtheria, and typhoid 
fever. Henry E. Armstrong, Medical Officer of Health at Xewcastle-on- 
Tyne, states (Practitioner, March, 1892) that " ten years ago the editor of 
the British Medical Journal showed that up to date 71 epidemics in England 
had been traced to milk — namely, 50 of enteric fever, 15 of scarlet fever, and 
6 of diphtheria, the total number of sufferers being 4800." He does not 
enumerate the cases of tuberculosis caused by infected milk, and yet recent 
observations justify the belief that such cases are not uncommon. 

Dr. H. C. Ernst (Boston Med. and Surg. Journ., Sept. 26, 1889) read a 
paper before the Association of American Physicians, in which he reviewed 
Koch's assertion that the milk of tubercular cows contains the tubercular 
bacillus, and is infectious only when tubercles are present in the udder or 
lacteal tract. In a large proportion of the tubercular cows examined by him 
the specific bacilli were present and active in the milk when the udders and 
teats were entirely healthy. Klein also believes that observations confirm 
the opinion (Glasgow Herald, May 27, 1889) that the milk of the tubercular 
cow may contain the tubercular bacillus in whatever part of the animal the 
tubercles are located. This theory, that the milk from a tuberculous cow, 
even when the lacteal tract is healthy, sometimes contains the tuberculous 
bacillus, and may therefore communicate phthisis, has been confirmed by 
others (Prudden). 

The following brief resume of cases reported by well-known clinical 
teachers shows the need of frequent and careful inspection as regards the 
presence of tuberculosis in the dairy which furnishes milk for the nursery : 
Ollivier (La Semaine medicale, Feb. 25, 1891) states that within three 
months, in a school for girls, there occurred eleven cases of tuberculosis, of 
which five were fatal, and with several of these patients the disease seemed 
to originate along the gastro-intestinal tract. Two other pupils of this school 
died of tuberculosis. Their previous excellent health and that of their 
parents justified the belief that they also contracted tuberculosis from the 
milk. On searching for the cause of this disease, it was believed to be the 
milk-supply, and on killing the cow that furnished the milk its lungs were 
found to be in an advanced stage of tuberculosis. 

Prof. Demme states that an infant of four months died from tuberculosis 
of the mesenteric glands. The microscopic examination revealed tubercle 
bacilli in glands partly cheesy. No anatomical changes indicative of disease 
were discovered elsewhere in the body, and the parents were healthy. The 
child had been fed from birth with uncooked milk from a cow that the physi- 
cian ordered killed. The left lung of the cow was found to be diseased, and 
it contained tubercle bacilli. A microscopic examination of the milk pressed 
out from its udder showed the presence of the pathogenic bacilli. Recently 
another similar case has been reported. A boy of four years, previously 
healthy and of healthy parentage, died of meningitis, diagnosticated tuber- 
cular, and it was believed by the attending physicians to have been produced 
by the use of milk from cows which were afterward killed and found to be 
tubercular. Mr. Law, in an able paper published in the 65th Bulletin of the 
Cornell University Experiment Station, remarks that " Hischberger inocu- 
lated rabbits in the abdominal cavity with the milk of twenty-nine tuber- 
culous cows, of which the udders were or appeared sound, and produced 
tuberculosis fourteen times." 



ARTIFICIAL FEEDING. 59 

Steigenberger relates the case of an infant of five months of healthy 
parentage. It had caseous glands and abscesses of the neck, apparently 
tubercular and attributed to the milk-supply. 

Dr. I. L. Porteus, F. K. C. S.E., has published the following interesting 
statistics relating to the subject under consideration: In countries, like Fin- 
land. Sweden. Northern Norway, and Lapland in the far north, in which cows 
are scarce and the reindeer furnishes the principal food, tuberculosis is rare, 
as it is also in Algeria, where milch cows are few and away from the cities. 
On the other hand. Porteus states that in Hannover, a dairying country, 
where cows are abundant, 60 to 70 per cent, of the cattle are tubercular, and 
in Edinburgh 2(5 per cent, are similarly affected. Mr. Law says : " In infected 
breeding and dairy herds in New York, consisting largely of mature cows, 
I have found a maximum of 98 per cent, and a minimum of 5 per cent, 
tubercular." 

Scarlet Fever, Diphtheria, Typhoid Fever Armstrong, the Health 

Officer, states that in Newcastle 12 cases of scarlet fever occurred in 28 
families that were supplied with milk by a dairyman whose family were 
affected with this disease. W. A. McLachlin of Dumbarton says that in 
one instance in his rural practice diphtheria was traced to water obtained 
from two sunken wells which received the drainage of adjacent houses and a 
graveyard. After the health of the community had been restored by closing 
the wells and obtaining water from a fresh source, a return of the diphtheria 
was traced to the washing of milk utensils with water from one of the wells. 
Dr. R. R. Francis, Health Inspector of Montclair, N. J., reports an epidemic 
of typhoid fever, numbering -15 cases, which was produced by the typhoid 
bacilli in milk. These cases were traceable to the milk supplied by a dairy- 
man in whose family typhoid fever had recently occurred (N. Y. daily papers, 
April 12, 1894). Many similar cases have been reported showing the causal 
relation of infected milk to diphtheria, scarlet and typhoid fevers, so that 
physicians, and to a certain extent the laity, are aware of this fact, and it 
would be superfluous to cite more instances. 

Not only do scrofula and malnutrition, in addition to the diseases men- 
tioned above, result from the use of impure milk, but in certain parts of the 
United States another malady not sufficiently investigated results from the 
same cause. 

Milk Sickness. — At the Tenth International Medical Congress, held in 
Berlin, a paper was read on the milk sickness occurring in central and west- 
ern portions of the United States. It appears to prevail in newly-opened 
settlements, disappearing when the soil is fully cultivated. Animals contract 
the disease when they pasture late at night or early in the morning. When 
sick they travel but little and hold their heads to the ground, and have as a 
rule constipation and poor appetite. Some recover, but those that die have 
tremors which continue three or four days before the fatal event. The use 
of milk from an infected herd communicates the disease to man. In man the 
symptoms are languor, anorexia, nausea, vomiting, pyrosis, constipation, and 
excessive thirst, dry skin, moist and coated tongue, difficult and sighing res- 
piration, retracted but not tender abdomen, no elevation of temperature, and 
no change of pulse. The symptoms of this unknown disease are like those 
of some vegetable poison. Its communication to children through the milk 
must be disastrous. 

Since cow's milk must be the substitute for human milk when the latter 
is wanting, and in all cases after weaning is the most important dietetic 
article during infancy and childhood, its exact composition and the nature 
of its ingredients should be understood. Human milk contains, on the aver- 
age, a little more fat or cream than cow's milk, and 2] per cent, more sugar. 



60 INFANCY AND CHILDHOOD. 

while of the albuminoids, mainly casein, the quantity in cow's milk is nearly 
twice that in human milk. 

Lactose or milk-sugar, deprived of spores and proteids, forms a white, 
translucent, and hard crystalline substance. It is regarded by chemists as 
intermediate between cane-sugar and starch, having little sweetness, but 
being soluble in water. By its oxidation in the system it produces animal 
heat. It is therefore an important ingredient in milk, being about one-half 
of its solid constituents. Its heat-producing property is especially needed in 
the young infant, whose normal temperature is 98.5° F., and whose feeble 
muscular movements have little effect in producing heat. Several microbes 
have the power to change lactose into lactic acid, according to the following 
formula: milk-sugar, Ci 2 H 22 O n -f- H 2 = 4(C 3 H 6 3 ) (Fownes). The change 
of milk-sugar into lactic acid occurs in normal digestion. Pasteur held that 
the change was produced by a fungus, the Penicillium glaucum, but late 
chemists attribute it to bacteria, as stated above. The formation of lactic 
acid is attended by curdling of the casein. By the presence of abnormal 
ferments the lactic acid sometimes undergoes a further change, producing 
alcohol and carbonic acid, according to the following formula : C 3 H 6 3 
— C 2 H 6 -J- C0 2 . This abnormal digestion causes flatulence, which is common 
in the bottle-fed infant, and is a frequent cause of fretfulness and disturbed 
sleep. Another abnormal fermentation, designated the butyric, sometimes 
occurs. It is really a putrefactive change, the lactic acid being converted 
into butyric and carbonic acids and water. This fermentation is represented 
by the following formula : 2C 3 H 6 3 (lactic acid) = C 4 H 8 2 + 2C0 2 (carbonic 
acid) 2H 2 (water). 

Fat or Cream. — The oil-globules in human and animal milk are not sur- 
rounded by an envelope, as was formerly believed, but albuminous particles 
are attracted to, and become adherent to, the globules, so as to serve the 
purpose of an envelope and prevent the globules from uniting with each 
other. 

Albuminoids. — These are chiefly casein and lactalbumin, and a small 
amount of peptones, perhaps produced by the action of microbes. Casein 
occurs in milk principally in combination with the alkaline base potassium, 
as a casemate of potassium. By the action of an acid not too concentrated 
bovine casein forms large coagula, and human casein forms particles like a 
coarse powder, and is therefore more readily digested. The lactalbumin 
separates from the casein and remains in the whey, but by the application 
of heat it coagulates like other forms of albumen. Not only is there the 
difference, as stated above, in the coagulation by the gastric juice of the 
casein in human and in bovine milk, but the proportionate quantity of casein 
in cow's milk is considerably greater than in human milk, as is seen by the 
table previously published. The excess of albuminoids in cow's milk is 
mainly an excess of casein. To this difference in the nature and quantity 
of casein in the two kinds of milk the fact is largely attributable that, while 
the infant digests easily and fully human milk, its digestion of cow's milk is 
difficult, frequently attended by gastro-intestinal pain and vomiting of caseous 
coagula or their appearance in the stools. 

Inorganic Matter. — This is between three and four times greater in bovine 
than in human milk. The excess is largely due to the potash and calcium 
phosphate existing for the most part in combination with the casein. In 
the ash of both human and bovine milk the following substances have been 
isolated : potash, soda, lime, oxide of iron, phosphoric and sulphuric acids, 
and chlorine. 

How to Obtain Good Cow's Milk. — If the milk employed in the nursery 
be of good quality and be given in proper quantity and at proper intervals, 



ARTIFICIAL FEEDING. 61 

and the digestive function of the child be in its normal state, we can con- 
fidently expect healthy digestion and the required nutrition and growth of 
the tissues. But slight disturbing agencies produce fermentative changes 
in the milk which are abnormal, and are manifested by vomiting, flatulence, 
gastro-intestinal pains and diarrhoea, with unhealthy and partially-digested 
stools. The frequency of this unhealthy digestion or fermentation of cow's 
milk when administered to young children, and consequent loss of flesh and 
strength, with dangerous even fatal prostration, are now fully recognized. 

It is evident that milk designed for the nursery should contain the proper 
proportion of nutritive constituents, and be free from pathogenic microbes 
and other impurities. No more important duty devolves upon parents than 
to procure milk which approaches as nearly as possible to this standard of 
purity and excellence. 

Dr. E. F. Brush of Mount Vernon, who has made a lifelong study of the 
habits of the cow, has directed attention to the fact that this animal, running 
at large in the pasture, is as likely to drink muddy and foul water, even that 
containing filthy and putrefying matter, as it is pure water, and to browse 
upon weeds which are noxious, even poisonous, so that such water and such 
weeds should be removed or excluded from the pasturage. Dr. Brush also 
calls attention to the fact that the cow during the oestrus or rutting period, 
during abortion, which he says is common, and after parturition, furnishes 
milk deleterious and dangerous for nursery use. He has observed cases in 
which such milk has caused severe gastro-enteritis. 

Fortunately, the laity as well as the medical profession are at last fully 
aware of the importance of obtaining milk from cows that are not only 
healthy, but are properly fed and cared for. It is a matter of the greatest 
importance that the presence of tuberculosis in the cow, which is known to 
be a common disease in the United States, can be readily detected by inject- 
ing tuberculin under the skin of the animal, since, thus employed, it causes 
fever in the tubercular cow, but not in one that is healthy. With this test 
many cows with tuberculosis in dairies supplying the New York market have 
been killed or excluded. Meal, grass, or hay of good quality without weeds 
constitute the proper food of the cow. Brewers' grains and swill in any 
form must be forbidden. The cows should be provided with airy stables, 
kept clean, and with abundant straw to lie upon. They should be supplied 
with pure and fresh water, and must not be stabled with other animals. 
Those upon whom devolves the task of milking and the subsequent care of 
the milk should have finger-nails, hands, and person scrupulously clean. 
The teats and udder of the cow should also be clean, free from cracks, sores, 
and indurations. They should be cleaned with a moistened sponge or other- 
wise immediately before the milking, so as to prevent hairs and foreign sub- 
stances from falling into the milk, and any milk rendered impure by the 
cows stepping into the pail or otherwise must be rejected. The milk, imme- 
diately after the milking, must be cooled to 50° F. or lower by being placed 
in running water or surrounded by ice, and the vessels containing it should 
be open half an hour to one hour to allow the gases to escape. The dairy 
supplying the milk should be frequently and fully inspected by a competent 
veterinarian, and all feverish and sick cows be excluded from the herd. Or. 
Woodhead very properly proposes (Brit. Med. Journ., Sept. 1\K 1891) that 
a regular staff of veterinary inspectors, educated and competent for such 
work, be appointed, who shall examine every two weeks the cows furnishing 
the milk-supply, and that they shall have the power to exclude from the 
herd cows having or suspected of having tuberculosis or other severe disease. 
and that it be penal for a milkman to offer in market the milk from a con- 
demned or suspected cow. No phthisical person or person recently exposed 



62 INFANCY AXD CHILDHOOD. 

to any communicable disease should be employed in any branch of the dairy. 
In preparing milk for the market it should be strained through fine gauze, 
and must not be exposed in any room in which there is dust or has recently 
been severe sickness. The bottles or cans sent to customers must in the 
transit be kept cool by ice around them, except in midwinter, and must be 
full, so as to prevent churning. 

In the cities at a distance from the dairies pure and wholesome milk for 
nursery use can be obtained in no other way than by strict compliance by 
dairymen and middlemen with the directions given above. No more import- 
ant duty devolves upon parents than to see that these directions are rigidly 
enforced. From the fact that this subject is engaging the attention of medi- 
cal societies it is probable that in the near future more rigid rules will be for- 
mulated for the control of the milk-supply of general applicability, which 
milk companies under written agreement will accept or lose their customers. 
Sterilization at a Low Heat — Pasteurization. — Since cow's milk is not only 
a vehicle, but a culture-bed of bacteria, and, though prepared for market 
with the utmost care, ordinarily contains more or fewer of them, some of 
which, as we have seen, are pathogenic, its sterilization before its use in the 
nursery becomes a paramount duty. 

The experiments of Pasteur and others have demonstrated the important 
fact that a temperature of 160° to 170° F., continued from fifteen to twenty 
minutes, destroys the germs of tuberculosis, typhoid fever, scarlet fever, 
pneumonia, and bacteria, as well as developed germs of almost any kind. 
The New Jersey State Dairy Commission reports that sterilization at the 
high temperature frequently employed diminishes the germicidal action pres- 
ent in raw milk. If cholera-germs be placed in fresh raw milk and in milk 
sterilized by heat, after three hours a smaller number of germs will be found 
in the former than in the latter. The lactalbumin, which is allied to serum- 
albumin, is coagulated by heat, rendering the milk more viscous, and pro- 
ducing the unpleasant flavor characteristic of boiled milk. By the action of 
heat the albumen is rendered less soluble and is apparently digested with 
more difficulty, A heat above 165° F. destroys the starch-fermenting in- 
gredient of milk, the galactozyme, which is an important loss to the young 
infant, whose saliva has not yet acquired that power. The milk-sugar is 
changed or destroyed. The fat or cream occurs in drops or pellicles upon the 
sterilized milk, and it is necessary that the digestive function should restore 
it to an emulsion before it can be absorbed. The casein is also changed by 
sterilization so as to be less readily and fully precipitated by rennet. Bagin- 
sky states that it requires more rennet and a higher temperature to effect the 
digestion of the casein of sterilized than of raw milk. Since sterilization 
produces the bad results noticed above, it is evident that sterilization at a low 
heat — (160° to 167°) — designated Pasteurization — since it is sufficient to de- 
stroy the pathogenic microbes, should always be recommended, and never a 
higher temperature. If by greater care in the management of the dairy and 
of the milk-supply the time ever arrives when the milk is free from microbes, 
its sterilization by heat or otherwise will not be required. 

Predigestion — Dilution. — Since human milk contains more fat and less 
casein than cow's milk, and since in the vessel holding milk the cream rises 
and casein sinks, the upper third may be advantageously employed for infants 
under the age of three months, and the upper half for those over the age of 
three months. By employing the upper part of the milk we are enabled to 
prepare a food which more closely resembles human milk, the aliment which 
Nature provides. 

When human milk cannot be obtained for the infant under the age of one 
year, the best substitute for it can be prepared from cow's milk mixed with 



ARTIFICIAL FEEDING. 63 

dextrinized barley or wheat gruel. My preference is for barley flour pre- 
pared as follows : Barley flour is placed dry in a double boiler and subjected 
to the heat of boiling water from five to seven days, the fire abating at night. 
All the nutritive properties are preserved by this method of employing heat, 
whereas by the old method of boiling the flower-ball in water some of the 
fat. soluble albuminoids, and mineral matters escape into the water and are 
lost. By the action of the heat the starch-granules swell and burst, and the 
starch consequently is more readily acted on by the diastase subsequently 
added. 

How to Prepare Dextrinized Barley Gruel and Cow's Milk for Nursery 
Use. — A heaped tablespoonful of the flour which has been subjected to the 
prolonged action of heat in the manner mentioned above should be added to 
thirty tablespoonfuls of boiled water for an infant of three months, or to 
twenty-five tablespoonfuls for one of six months, and boiled from three to six 
minutes to facilitate admixture. When it has cooled to blood-heat half a 
drachm or perhaps one drachm of diastase (Forbes's or other of good quality) 
should be added to it. This in a few minutes changes the starch into dextrin 
and maltose. This predigestion renders it thinner and a useful and conve- 
nient diluent for the milk. 

The most indigestible constituent of cow's milk is the casein. While the 
relative proportion of it is diminished by employing the upper third or half 
in the bottle or can, the addition to it of the dextrinized gruel mechanically 
separates the particles of casein, and tends to prevent the formation of thick 
curds and promote a loose and friable coagulation, so that it is more readily 
digested than the casein of milk not treated in this manner. 

But the feeble digestive power of the young infant can be greatly assisted 
by adding to the milk the so-called " Peptogenic Milk Powder," consisting of 
pancreatin, lactose, and the alkaline milk salts, a digestive mixture devised by 
Fairchild Brothers & Co. This supplies a desideratum long needed. This 
peptogenic milk powder is prepared for use both in tubes and in cans, the 
latter containing the measure of the quantity to be employed for a certain 
amount of milk. 

Different pediatrists have published formulae showing the frequency of 
feeding and quantity of food proper for infants of different ages, the food 
being prepared so as to resemble as nearly as possible human milk in bulk 
and nutritive properties. But if dextrinized gruel, which is readily absorbed 
and assimilated, be employed as a diluent of the milk, the quantity or bulk 
would probably be greater than that stated in most of the dietary tables. 
Infants, especially those under the age of three months, sometimes do well 
with the dextrinized barley gruel in excess of the predigested milk, and 
infants with feeble digestion are sometimes benefited by taking a few drops 
of pepsin or other digestive ferment before each feeding. Thus at the pres- 
ent time, at midsummer, when so many of the bottle-fed are attacked by 
the summer diarrhoea, a bottle-fed infant of five months remains in the best 
of health, being fed every two hours during the day with dextrinized barley 
gruel three and a half ounces and Pasteurized and peptonized upper half 
of milk two and a half ounces. Each feeding is preceded or accompanied 
by a dose of a few drops of one of the digestive ferments. The number of 
feedings is about nine or ten in twenty-four hours. I have in a number of 
instances seen infants under the age of three months thrive and escape the 
dreaded summer diarrhoea when fed with two parts of the dextrinized gruel 
mixed with one part of the Pasteurized and peptonized upper half of the 
milk. Some infants do better if the amount of water at each feeding be 
half an ounce or one ounce greater. 

A word should be said in reference to the use of condensed milk. oY which 



64 INFANCY AND CHILDHOOD. 

there are four or five kinds in market. If sufficiently fresh and diluted with 
dextrinized barley gruel, it answers very well, according to my observation, 
in an emergency. It is sterilized by the heat required for condensation, and 
the barley flour properly prepared in a double boiler, and when made into a 
gruel treated with diastase, supplies fat, dextrin, and maltose, which the infant 
can readily digest. I therefore frequently recommend it when there is diffi- 
culty or delay in obtaining good milk. In recommending fresh condensed 
milk I should state that my question to the company, How much water is 
expelled from the milk by the heat of condensation ? was never answered ; 
but in practice I have recommended to add two heaped teaspoonfuls of the 
milk to fifteen of water, boiled, as the equivalent of seventeen teaspoonfuls 
of ordinary milk. 

In no institution in America are there so many young foundlings nourished 
by the bottle as in the New York Foundling Asylum. At the present time 
in one ward are thirteen bottle-fed infants under the age of two months, and 
they receive every two hours, preceded by six or eight drops of the essence 
of pepsin or the elixir of digestive ferments, one ounce each of the dextrin- 
ized barley gruel and the Pasteurized upper part of milk. Never before 
have these waifs escaped to such an extent the summer diarrhoea and vomit- 
ing which have heretofore been very fatal. 

My purpose is to recommend a mode of alimentation which can be easily 
employed by the poor in tenement-houses as well as by those in better circum- 
stances, and which I think will be more successful in saving life than the 
modes of alimentation which are in common use. 

After the first year the food may be made of such consistence as to be 
given with the spoon. In the second year and subsequently a pap may be 
made of stale bread boiled in water sufficient to cover it, and mixed with 
fresh milk, care being taken that all lumps are reduced to a pulp. Beef tea 
is a laxative on account of the salts which it contains, as is also chicken tea, 
but a small or moderate amount of it may be given once or twice a day, 
preferably made into a light pap with a soda cracker or stale bread. Few 
vegetables are proper for infants under the age of one year, but the potato, 
baked and mashed so as to be like flour, may be given at the tenth or twelfth 
month. It contains a large amount of starch, but appears to be readily 
digested by infants of the age mentioned if given once a day in moderate 
quantity, with a little butter and salt added. In the second year a greater 
variety of food may be allowed, but the full diet of the table must not be 
given till after infancy, or at the age of three years. In the beginning of 
the second year the infant is weaned. He has twelve teeth, eight incisors, 
and four molars, which, with their broad surfaces, are designed for chewing. 
Let him have now, once or twice each day, in addition to the food which has 
previously been employed, a small piece of roast beef, rare done and cut very 
fine. Other meat, as mutton, may sometimes be given instead. After the 
age of eighteen months light puddings of farinaceous substances, properly 
prepared, as of rice and corn meal, may be added to the dietary. 

All the teeth of the first set have appeared at the age of two years and 
five months, and the time has now arrived when a more marked transition 
may be made from liquid to solid food. Certain fruits may be allowed even 
before this period, as also the jellies of most berries and of fruits, which 
being deprived of seeds and parenchyma are for the most part readily 
digested, while they give a relish to the farinaceous food with which they 
are eaten. Pastries as ordinarily made, whatever fruits they may contain, 
are too rich and indigestible for young children. 



BATHING, CLOTHING, SLEEP, EXERCISE. 65 

CHAPTER IX. 

BATHING, CLOTHING, SLEEP, EXEECISE. 

Bathing is now recognized in all civilized countries as one of the chief 
promoters of bodily comfort and health. The first bathing of the infant, 
which is immediately after birth, should be in water at a temperature a little 
below that of the blood — namely, at about 96° — after which the general 
bath is inadmissible until the navel-string is detached. In the infant reaction 
of the surface when chilled is tardy and uncertain, and therefore there is 
great danger of catching cold when the surface is cooled by water and does 
not quickly react. It is a matter of daily observation that infants become 
chilly and their extremities remain cool in a medium, whether air or water, 
in which older children and adults would have comfortable warmth. There- 
fore they are liable to contract bronchitis, sore throat, intestinal catarrh, or 
other inflammation from very slight exposures. This fact must be borne in 
mind in considering the subject of bathing. 

During the first year after the detachment of the navel-string the bath 
should be employed daily, but not longer than three minutes, during which 
time thorough ablution can be performed. Different authorities disagree in 
regard to the proper temperature of the bath during the first months of 
infancy. Steiner of Prague, a high authority in children's diseases, says : 
" During the first nine months the infant should have a daily bath a little 
above blood heat," but most authors recommend a temperature a little below 
blood heat. In my opinion it should be at 92°, which is considerably below 
blood heat, but which communicates a moderately warm sensation to the hand. 
After the age of ten months, or even of eight months for vigorous children, 
the temperature of the bath may be reduced to 90°, and it should not be 
lower than this during the remainder of infancy, or if it be used a little 
lower care should be taken to produce reaction by brisk rubbing and exercise 
after a short bath. At the close of infancy, or at two and a half years, the 
temperature may be still further reduced, but it should not, even for the most 
robust children of eight or ten years, be below 78°, which is recorded on our 
thermometers as the temperature of summer heat, and is about that of our 
northern lakes during midsummer. 

The rules given in the books, not to bathe or direct a child to be bathed 
immediately after eating or after much exercise, when the pores of the skin 
are perspiring, should be heeded. The head should first be wet with the 
water, and castile soap should be applied over the surface to ensure cleanli- 
ness. The strongly-scented toilet soaps sometimes contain rancid fats or 
other deleterious substances, and should be regarded with suspicion. In hot 
weather a daily bath is advisable, but in the cooler months it is sufficient if 
the child bathe twice or three times in the week. If, from lack of conveni- 
ences or for other reasons, general bathing be dispensed with and the surface 
be washed from a basin or bowl, cooler water may be used than would be 
proper for the general bath, and a longer time to complete bathing would 
evidently be required. The bath-room should be comfortably warm, and 
after the bath the surface should be briskly rubbed with flannel or. in case 
of older children, with a suitable coarse towel, and exercise afterward encour- 
aged to ensure full reaction. In New York, in one of the largest and best 
managed asylums, both boys and girls are allowed to bathe in bath-houses in 
the Hudson when the water and weather are not too cool. 



66 INFANCY AND CHILDHOOD. 

It may be well to add to these general remarks on bathing the recent 
statement of a high authority on therm ometric observations and temperature, 
that during hot days a bath in hot water, employed in the hours of greatest 
atmospheric heat, tends to reduce the heat of body and to preserve its normal 
temperature during the remainder of the day. Wunderlich says : " In tropical 
countries and in very hot seasons no means of cooling is so lasting as a bath 
or douche of very warm water." 

Clothing. 

One of the most important duties of the mother or nurse is the selection 
of clothing for children which will be suitable for their age and the season. 
In the matter of dress, as in that of diet, many errors are unconsciously 
committed. In a room of proper temperature, which during the cool months 
should be 70° for infants and 68° for children old enough to run about, the 
head should never be covered unless in case of young infants ; but the sides 
of the head, as well as the neck and shoulders, may be lightly covered in 
sleep. It is the common practice to leave off the " bellyband," which is 
applied after birth, when the infant has reached the age of three or four 
months ; but from the fact that infants so often take cold, especially at night 
by throwing off bedclothes, both in cool weather, when the temperature of 
the apartment may fall below 70°, and in summer, when there are currents 
of air through open windows, I advise the continuance of the band during 
the first year or eighteen months. In the summer it should be made of light 
merino and in the winter of flannel. It should never be so thick and heavy 
as to be uncomfortable, or so snug as to interfere in the least with the free 
movements of the chest and abdomen in respiration. It should extend to 
and not over the ribs, and should be secured either with safety-pins or a few 
stitches. If excoriations or prickly heat appear on the skin under the band 
in hot weather — a very common eruption in infancy — the surface should be 
dusted with equal parts of subnitrate of bismuth and stearate of zinc, or a 
mixture in equal parts of lycopodium and oxide of zinc, and a single layer 
of linen should be applied over it and under the band. If the eruption be 
severe, it might be best to substitute a linen or soft muslin band for a time 
in place of the merino. 

A cardinal principle in the clothing of children is that the garments should 
always be so loose as not to interfere in the least with the functional activity 
of organs. The fitting and putting on of the dress is left too much to the 
discretion of the nurse, who is usually ignorant of the important facts in 
physiology, and unwittingly and with the best intentions injures her charge. 
I have often interposed to loosen the dress of young infants, which was so 
tight as sensibly to embarrass respiration ; and the case of a new-born infant 
has been reported to me in which it seemed probable that death resulted from 
this cause. Infants especially, who are so liable to pulmonary collapse and 
intestinal hernia, should have loose covering of both chest and abdomen. 
Pressure over the stomach always feels uncomfortable, and this organ, almost 
as much as the lungs, needs full expansion and free movement in order to 
perform its function of digestion properly. The same is true also of the 
intestines, but they tolerate compression better, and their movements are less 
impeded than those of the stomach by too tight dressing. Another part 
where too snug an application of the dress does very great harm is the neck, 
since moderate pressure in this region may retard the circulation of blood 
through very important vessels — to wit, those which supply the brain or return 
blood from this organ. The dress about the neck should always be so loose 
that the four fingers of the nurse can be readily introduced underneath it. 



BATHING, CLOTHING, SLEEP, EXERCISE. 67 

Skirts upon girls are sometimes supported by being tied tightly around the 
waist and over the stomach. This should never be allowed, but they should 
always be supported by shoulder-straps and be loose around the waist. 

Clothing protects the body according to its thickness and the feebleness 
of its conducting power of heat. Woollen, fur, and feather garments have 
very low conducting power, and wool, from its plentiful supply and cheap- 
ness, must always be the material which is chiefly worn in the winter season ; 
while cotton, and in still greater degree linen, are active conductors of heat, 
allowing its quick escape from any part of the body which it covers, and 
they are therefore the proper material for summer clothing. 

The color of the garment matters little as regards the escape of heat from 
the body, for whatever its color its surface next the body is necessarily dark 
from the exclusion of light ; but the color is important as regards the 
absorption of heat from the atmosphere and the solar rays. Black has the 
highest absorptive power, while white has the least, and the mixed colors 
have absorptive powers which are intermediate. In experiments made with 
shirtings of different colors, while white received 100° F., black received 
208° F. A light color is therefore the best to dress children in during the 
hottest weather. 

The covering which is proper for the head of a child when outdoor must 
evidently vary considerably in different seasons and in different states of 
weather. Many a young child with scanty growth of hair has contracted 
that painful disease, inflammation of the ear, followed perhaps by a protracted 
discharge and more or less impairment of hearing, in consequence of taking 
cold from insufficient covering of head and ears in inclement and changeable 
weather ; even leaving off accidentally a band or tie which a child is accus- 
tomed to will sometimes give it a cold. 

In this connection I wish to call attention to the common and dangerous 
practice among the poor of allowing children to go bareheaded in the sun 
during the season when the atmospheric heat is highest. Not a summer 
passes in which I do not meet cases of inflammation of the brain which I 
believe to be largely due to exposure to the sun's rays. There is no better 
and safer covering for the head of a child who is allowed to go in the open 
air during the hot weather than the light, cool, and inexpensive straw hat. 

The feet should always be warm and dry, the shoes worn in wet weather 
being waterproof, and special care should be taken in the selection of shoes 
that they be pliable and loose, so as to allow freedom of growth without com- 
pression of any part. If during the period of growth proper precautions are 
taken in this respect, the chiropodist would have little to do in subsequent 
years. Corns, bunions, and ingrowing toe-nails orginate from hard and un- 
yielding or too tightly-fitting shoes. 

■ 






Sleep. 



The newly-born infant until about the age of six or eight weeks requires 
not less than twenty-one hours' sleep each day. It sleeps, therefore, most of 
the time when not awake for the purpose of nursing, bathing, and change of 
clothing. If it do not have this amount of sleep and be wakeful, it is prob- 
ably not well. After the eighth week it requires less and less sleep with 
advancing age, and at the end of the first year fourteen hours of sleep each 
day suffices. At the age of eighteen months about twelve hours of sleep are 
needed, a part of which should be in the middle of the day. At the age of 
two and a half or three years, and subsequently during childhood, about ten 
hours are required at night, and if the child be tired or sleepy in the day- 
time it should be allowed to sleep. Sufficient sleep is essential for the nor- 



68 INFANCY AND CHILDHOOD. 

mal development of the body and the normal functional activity of the 
organs in infancy and childhood. 

During sound sleep the senses no longer receive and communicate impres- 
sions. They enter into the state of sleep in the following order : Sight is 
first lost, and then touch, taste, smell, and lastly hearing. In sound sleep 
also the frequency of the respiration and pulse is slightly diminished. Exci- 
tation of any of the senses has a tendency to prevent sleep. A bright light, 
rough handling, and loud noises render young children wakeful, and. if they 
be deprived of the needed sleep, fretful. Slight excitation of certain of the 
senses, as by a low humming voice or gentle rocking, on the other hand, tend 
to procure sleep. The time of soundest sleep is about one hour after its 
commencement, after which it becomes gradually less profound until the 
child awakens. The child should be habituated to taking its sleep at a cer- 
tain hour, and if it be well and not subjected to any unusual excitement, it 
will be drowsy and will sleep readily when that hour arrives. In the asylums 
of New York, where from long and abundant experience the management of 
children is systematized, infants and the younger children are usually put to 
bed between six and seven, and the older children between seven and eight, 
o'clock, the last meal being light and readily digested. 

Various causes produce wakefulness in children. We have already alluded 
to strong impressions upon the senses. A swollen and tender gum, indiges- 
tion with flatulence and colic, eczema with tenderness and itching, as well as 
the more serious forms of sickness, produce wakefulness. Unpleasant and 
exciting sensations of whatever kind, reaching the brain, keep up a state of 
excitement and prevent its repose. The fretful and sleepless baby in the hot 
and stifling air of the tenement-house in the heat of summer soon falls asleep 
when taken to cooler air outside. 

It is scarcely necessary to call attention to some accepted and important 
facts regarding the dormitory of children. Free ventilation is required either 
through ventilators or through the windows, slightly raised in winter and 
more widely open in summer. A small room should not contain more than 
two children, and the temperature of the sleeping apartment should be at 
about 68° F. A temperature too cool causes wakefulness. 

The amount of blood circulating in the brain in sleep is less than when 
awake, and too active a circulation, as from fever or much excitement, causes 
wakefulness. If the head be unduly hot, and in the infant the anterior fon- 
tanel pulsate forcibly, a cloth wrung out of cold water should be applied over 
it, and a general bath or hot foot-bath should be used in order to diminish the 
cerebral circulation. On the other hand, if the brain be not properly nour- 
ished in consequence of poverty of the blood, as is sometimes the case with 
pallid and scrofulous children, the diet should be more nutritious and iron 
may be needed. 

If the sleeplessness continue when all causes so far as possible have been 
removed, medicinal treatment will be necessary. Frequently in families 
before the physician is summoned the so-called soothing syrups have been 
used, which contain an opiate, and the use of which should be forbidden. The 
safest remedy is one of the bromides, which may be given dissolved in water 
in three-grain doses to an infant between the ages of six and twelve months, 
and one grain additional should be added for each year, or the aniseed cordial 
of the National Formulary may be prescribed. The dose if required may be 
repeated after two hours. 

Exercise. 

Exercise is an important hygienic requirement. Harm often results from 
modes of exercise which are not adapted to the age. Occasionally I meet 



BATHING, CLOTHING, SLEEP, EXERCISE. 69 

cases of permanent bow-leg which have manifestly resulted from attempts to 
make infants stand at the age of four or five months. They should never be 
encouraged to walk or stand till about the age of one year, and if they do at 
the age of nine or ten months, let it be voluntary and not taught by stand- 
ing them upon their feet. In case of infants with rachitis — which disease is 
common in cities, and is characterized by a lack of lime-salts in the bones, 
and can be detected by great backwardness in teething — attempts to stand 
or walk for any length of time should be discouraged till by the use of phos- 
phorus, cod-liver oil and improvement of the general health the rachitis is 
cured. Much of the permanent deformity which mars the beauty and sym- 
metry of adult life orginates in rachitis and might have been prevented. 

The infant before he is old enough to stand takes sufficient exercise in a 
way that is natural and harmless. Let him lie upon his back in the crib or 
on the floor, with a blanket under his body and pillow under his head, with 
all his clothes loose, so as not to restrain the free movement of his limbs. A 
healthy infant seems to enjoy this attitude, moving all his limbs sufficiently 
to give them the required exercise, and evincing his delight and exuberance 
of life by utterances which are as expressive as words. 

In the cool months of our latitude infants should not be taken outdoor 
until the age of three months, and then only for a brief time in the warmest 
part of the clay ; but in the summer they should begin to receive outdoor air 
and exercise at the age of one month. In warm weather the face should 
never be covered by a veil or otherwise, and air and light should have free 
access to it. The rays of the sun, however, from a clear sky should be 
excluded, either by a parasol or the shade of trees or houses or by the carriage 
in which the infant is conveyed. In cold weather or when there is a strong 
wind the protection of a veil is needed. Rude tossing of infants, which is 
common in families, should always be forbidden. Its effect on the cerebral 
circulation is likely to be bad, and it involves risk of serious accident. In 
one instance to my knowledge death resulted from injury received in this 
way. 

Walking, as it is the natural, so it is the best, exercise for the older infants 
and during the period of childhood. It promotes digestion when not carried 
to the extent of fatigue, and gives gentle exercise to all the muscles. The 
baby-carriage answers a useful purpose when combined with walking. With 
the ordinary hired nurse it is safer for the infant to be taken out in this 
vehicle than in the arms, for if the nurse in careless walking should trip great 
harm might result. In one instance which came under my notice convulsions 
and idiocy were plainly referable to the fall of an infant from its nurse's 
arms upon its head. 

The ordinary lawn sports of childhood, as croquet for both sexes, play- 
ing ball or quoits for boys, which are rendered more exciting by the spirit of 
rivalry, are also useful for muscular exercise and development, while they 
involve little danger. The swing affords a pleasant exercise, and with the 
propulsion required it gives gentle but efficient activity to most of the 
muscles. 

Many of the gymnastic exercises are too severe, involve too much risk 
of ruptured tendons, sprained joints, and even of dislocated or broken 
limbs. 

Among all the ingenious inventions to provide sports and pastimes for 
children there are none better than gardening and farming where facilities 
will allow them, conjoined with the ordinary household duties. The healthy 
and robust development of the farming population, their almost complete 
immunity from rachitic and scrofulous ailments, are attributable to their out- 
door mode of life and the many kinds of healthful work which farm-life 



70 INFANCY AND CHILDHOOD. 

requires. Such work is always in the highest degree beneficial for children 
old enough to participate in it, while it develops the habit of productive 
industry. 



CHAPTER X. 

DIAGNOSIS OF INFANTILE DISEASES. 

General Observations. 

Diseases in early life differ in important particulars from those occurring 
in maturity. Some which are common in the former age are unknown or are 
rare in the latter, and those which occur equally at all ages often present 
peculiar symptoms and a peculiar clinical history in the young. Therefore 
physicians who are skilful in treating adults may be unskilful in treating 
children. Excellence as a physician of children can only be achieved by 
special and continued study of their ailments. 

Again, as regards the diseases of infancy, in which period there are a great 
amount of sickness and a large mortality, diagnosis must evidently be made 
from the objective symptoms — from examining the features, attitude, utter- 
ances, the pulse, respiration, etc., and inspecting the surfaces, so far as they 
are accessible to view, and the eliminated products. We lack for this age the 
important information which speech affords. Some general remarks, there- 
fore, in reference to the appearances and functions of the system in early life, 
and the changes which they undergo in various pathological states, seem 
requisite in order to a clearer appreciation of the symptoms and more ready 
diagnosis of individual diseases. 

Features— External Appearance of the Head, Trunk, and Limbs 

in Disease. 

In the new-born, as soon as respiration and the new circulation are estab- 
lished, the cutaneous capillaries become distended with blood and the skin 
presents a congested appearance. By the close of the first week this external 
hyperemia begins to abate, and is soon replaced by the normal capillary 
circulation. 

The surface or portions of the surface of the new-born often present for a 
few hours a livid color, due to the mode of delivery. Protracted lividity 
occurs from atelectasis or malformation of the heart or great vessels ; lividity 
induced by exertion or excitement, while the respiration is normal, indicates 
malformation of the heart or vessels ; temporary lividity sometimes occurs in 
severe acute diseases, especially those of the respiratory organs : lividity, 
whether temporary or permanent, is a sign of imperfect decarbonization of 
the blood. 

The cheeks of children are congested in febrile and inflammatory diseases, 
except in a cachectic or prostrated state of the system. Transient circum- 
scribed congestion of the face, ears, or forehead constitutes a reliable sign of 
cerebral disease. Strabismus occurring in connection with febrile reaction, 
oscillation of iris, inequality of pupils, and drooping of upper eyelids, also 
denote cerebral disease. The pupils are contracted during sleep, evenly 
dilated in death. 



DIAGNOSIS OF INFANTILE DISEASES. 71 

Dilatation of the alas nasi during inspiration, with contraction of the eye- 
brows and a countenance indicative of suffering, attends severe inflammation 
of the respiratory organs. Absence of tears during the act of crying shows 
a severe and probably fatal form of disease in infants over the age of four 
months. 

Rapid wasting of the features, causing deep suborbital depressions, prom- 
inence and pointedness of the cheek-bones and chin, and hollowness of the 
cheeks, are signs of severe diarrhoeal malady ; the most striking examples of 
this sudden collapse of features are afforded by patients affected with cholera 
infantum. In severe cases of this disease the physiognomy, from a state of 
fulness and health, presents in a few hours such a wasted and senile appear- 
ance that the friends with difficulty recognize the features with which they 
are familiar. Muscular tonicity is also greatly impaired in this disease — that 
of the orbicular muscles of the lips and eyelids to such an extent that the 
mouth is open and the eyeballs exposed during sleep. Great emaciation 
occurring gradually is a symptom of subacute or chronic disease of a grave 
character, often of tuberculosis or chronic entero-colitis. 

Strabismus sometimes occurs in children who have no serious disease. It 
is then due to simple paralysis of one or more of the motor muscles of the 
eye. But when supervening upon other symptoms of a neuropathic charac- 
ter it is a grave symptom, indicating organic disease of the encephalon, as 
effusion, meningitis, etc. A permanently downward direction of the axes of 
the eyes, with smallness of the face and great expansion of the cranium, is a 
sign of chronic hydrocephalus. The scalp in this disease is tense, bald, or 
sparingly covered with hair, the fontanelles and sutures open and enlarged, 
and the cranial bones yield to pressure. Great expansion of the cranium 
above the ears, while the frontal portion is not enlarged or but slightly, 
denotes hypertrophy of the brain. 

The appearance of the general cutaneous surface possesses much greater 
diagnostic value in the diseases of infancy and childhood than in those of 
adult life. The eruptive fevers, so common in the young and comparatively 
rare in the adult, reveal themselves to us in great part by the changes which 
they cause in the appearance of the integument. The peculiar color of the 
skin in constitutional syphilis, hereafter to be described, and which is more 
marked in infancy and early childhood than at any other age, is a diagnostic 
sign of great value in obscure cases. In the infant the cold stage of inter- 
mittent fever is manifested, not by muscular tremors, but by lividity, pallor, 
and the goose-skin appearance of the surface. 

Bulbous enlargement of the fingers and incurvation of the nails are signs 
of cyanosis, and therefore of malformation at the centre of the circulatory 
apparatus, or of tuberculosis or chronic pulmonary disease attended by mal- 
nutrition. Enlargement of the spongy portions of bones, causing prom- 
inences, softness, and bending of the bones, and consequent deformity of the 
limbs, patency of the fontanelles, a large and square shape of the head from 
calcareous deposit external to the cranium, and delayed dentition, are among 
the signs of rachitis. 

In early infancy the glands of the skin and mucous surfaces, or which 
connect by their orifices with these surfaces, are slightly developed. There- 
fore, sensible perspiration and lachrymation are rare under the age of three 
months. A thick Meibomian secretion of a puriform appearance collecting 
between the eyelids in a state of great depression is an unfavorable prognos- 
tic sign ; it is observed most frequently in cerebral and intestinal maladies 
shortly before death. Passive congestion of the vessels of the conjunctiva 
sometimes occurs under the same circumstances, due to feebleness ot' the 



72 INFANCY AND CHILDHOOD. 

heart's action and imperfect capillary circulation. It indicates the near 
approach of death. 

Attitude— Movements— The Voice. 

A sharp, piercing cry, head firmly retracted, flexure of the limbs with a 
degree of rigidity, abduction of the great toe, clonic or tonic spasm of the 
muscles, irregular movements of one or more limbs, with consciousness im- 
paired or with mental hallucinations, are symptoms of grave disease of the 
cerebro-spinal system. Irregular muscular movements, partly controlled by 
the will and occurring during full consciousness, are symptoms of chorea, a 
disease nearly always ending favorably in children, though incurable in the 
adult. Contraction of the eyebrows, turning of the eyes and face from light, 
avoidance of noises as if painful, are signs of headache. Frequent carrying 
of the hand to the ear and pressing with the ear against the breast of the 
mother or nurse are symptoms of otalgia. Frequent carrying of the fingers 
to the mouth in connection with fretfulness or other symptoms of suffering 
indicates stomatitis, gingivitis whether from difficult dentition or other causes, 
painful pharyngitis, or some obstructive disease of the larynx. Frequent rub- 
bing or pressing the nose may be due to intestinal worms or intestinal irrita- 
tion from other causes. It may be due to coryza or headache. Frequent 
forcible rubbing or striking the nose should lead to a careful examination and 
perhaps guarded prognosis. It often indicates grave cerebral disease, and may 
be a precursor of convulsions. 

In severe obstructive disease of the larynx the child is restless, moving 
from side to side. In most inflammations of the respiratory organs a semi- 
erect position gives most relief. The voice in severe laryngitis is often hoarse 
or indistinct, and is usually so in the pseudo-membranous form ; in pleuritis 
or pneumonitis it is restrained or abrupt, since the movements of the walls 
of the ehest give pain. 

The voice in severe diseases of the abdominal organs is feeble and plain- 
tive. It is sometimes short and restrained in acute dyspepsia, in peritonitis, 
and in cases of great abdominal distention. The horizontal position gives 
most relief in abdominal diseases. In case of abdominal pain the patient 
often presses his hand upon the abdomen and flexes his thigh over it. Per- 
fect quietude, with features sunken and unchanged by smile or crying, is a 
symptom of severe and exhausting diarrhceal affections. 

Respiratory System. 

The respiration of the infant under the age of six months is very irregular, 
and it is more irregular the nearer the time to birth. If the new-born infant 
be closely observed, it will be seen to sigh often ; it breathes pretty uniformly 
and regularly for a moment, and then, without appreciable cause, the respira- 
tion is intermitted ; it holds its breath when it smiles or moves its head or 
even its limbs ; it is very subject to hiccup ; this is more common the first 
week of life than at any other age. So much is the breathing of the young 
infant disturbed by these causes that the number of respirations ordinarily 
varies in consecutive minutes. In order, therefore, to determine with accuracy 
the frequency of the normal respiration for this time of life it is necessary to 
take the average of several observations. 

At birth, while the function of the heart has for months been regularly 
performed, the lungs are still quiescent. The one organ has been active dur- 
ing the greater part of foetal development, the other is yet untried. Here- 
after, in the new order of things, so intimate is the relation between the heart 
and lungs that the proper performance of the function of the one is essential 



DIAGNOSIS OF INFANTILE DISEASES. 73 

to that of the other. Therefore, the commencement of respiration and the re- 
turn of circulation, which latter is modified and temporarily arrested at birth, 
are nearly simultaneous. Respiration begins in the first half minute of inde- 
pendent existence ; often, indeed, attempts to inspire occur before delivery is 
completed. The exceptions to this early establishment of respiration are after 
tedious or unnatural births. The establishment of the new circulation is a 
moment later. 

Respiration in Health. — As the air-cells at birth are closed, the establish- 
ment of respiration is difficult. The air at first penetrates a few pulmonary 
cells, but gradually more and more are inflated through the forcible inspira- 
tions which the crying of the infant produces, till after a variable time respi- 
ration becomes easy and complete. If the cry be feeble, and especially if with 
this feebleness there be considerable congestion of the brain, the result of 
tedious birth, the full establishment of respiration is in a corresponding degree 
gradual and slow. 

The frequency of respiration in healthy infants has been stated in a pre- 
ceding chapter. 

As the child advances from the age of one year the number of respira- 
tions per minute gradually diminishes, but through the whole period of child- 
hood it remains greater than in the adult. At the age of five years, when the 
child is quiet but awake, it is about 27 ; at the age of ten years, about 22. 

Respiration in Disease. — In cerebral diseases the respiration becomes slow, 
and, if somnolence occur, intermittent and accompanied by sighing. In young 
infants, in the drowsiness which supervenes when the blood is imperfectly 
decarbonized during severe attacks of capillary bronchitis or broncho-pneu- 
monia, respiration is likely to be intermittent. 

In inflammatory diseases of the larynx and trachea respiration is but 
slightly accelerated, and, if there be no obstruction, its rhythm is normal ; 
if there be obstructive disease, its rhythm is altered ; the inspiratory act is 
lengthened. In bronchitis respiration is accelerated in proportion to the 
degree of extension downward of the inflammation. It is in no disease more 
accelerated than in severe capillary bronchitis. 

In pleuritis and pneumonitis the respiration is accelerated in proportion 
to the extent and acuteness of the inflammation. Inspiration ending abruptly 
and succeeded by an expiratory moan is a symptom of both pleuritis and 
pneumonitis in their acute stages. In certain cases of irritative or inflam- 
matory disease of the abdominal organs respiration presents a similar charac- 
ter ; it is modified in this manner in consequence of the pain experienced in 
movements of the diaphragm. Ordinarily, however, in abdominal diseases, 
respiration is nearly natural. 

The cough is an important diagnostic symptom. It is loud and sonorous 
in spasmodic croup, hoarse or harsh in true croup, clear and distinct in bron- 
chitis, suppressed and painful in the early stages of pneumonitis and pleuritis, 
convulsive and with more inspirations than expirations in pertussis. A cough 
due to coexisting bronchitis is one of the first and most constant symptoms of 
measles. Typhoid and remittent fevers, difficult dentition, intestinal worms, 
irritating ingesta, and severe burns sometimes give rise to a cough which is 
nearly dry and painless. Occurring in such diseases, it is sometimes depend- 
ent on more or less bronchitis, to which the primary disease has given rise. 

A strongly-marked nasal or palatal cry is present in syphilitic ozsena, 
hypertrophied tonsils, and paralysis of the soft palate. If these can be 
excluded, it indicates retropharyngeal abscess. On one occasion Politzer 
heard this cry in a baby that the mother said was well ; but he introduced 
his finger in the fauces, felt the expected swelling, and by an incision evac- 
uated a considerable amount of pus. 



74 INFANCY AND CHILDHOOD. 

An excessively prolonged, loud-toned expiration, with normal inspiration 
and without dyspnoea, is, according to Politzer, an early symptom of chorea, 
sometimes preceding all other symptoms. He was once called to a child, 
apparently well and asleep, in whom this symptom had continued two hours r 
and was supposed by the mother to indicate croup. Later the ordinary 
symptoms of chorea appeared. The same author regards a high thoracic, 
continued sighing inspiration as almost pathognomonic of weak heart and 
of certain cases of acute fatty heart. Unlike the condition in laryngeal 
stenosis, while the diaphragm is nearly inactive the accessory muscles of 
inspiration act strongly. This symptom occurs early, antedating the lividity, 
pallor, weak pulse, and cold extremities. 

A distinct pause after each expiration, ascertained in a quiet room by 
placing the ear close to the mouth, distinguishes laryngeal catarrh from croup 
(Politzer). Stridulous inspiration usually indicates acute laryngeal catarrh, 
but I have, in a considerable number of instances, been asked to prescribe for 
infants with stridulous respiration which commenced early, perhaps in the 
first or second month, and continued night and day till about the close of 
the first year, when, in the development of the child, it ceased. It is attended 
by no dyspnoea or suffering, does not interfere with the nutrition or growth, 
is not benefited by any known treatment, and it seems that it may exist 
within physiological limits. 

A shrill, loud cry, night after night, in sleep, while the child is well in the 
day-time, is probably due to dreams, and it may be treated by a large dose 
of quinine at bed-time, but a full dose of the bromide of potassium or sodium 
is perhaps more likely to give relief. A cry lasting five or ten minutes and 
occurring several times in the day indicates spasm of the bladder, especially 
if dysuria be present. It is best treated by belladonna, provided that there 
be no calculus. A cry during defecation indicates fissure of the anus, and 
is to be treated by an ointment of zinc and belladonna. A violent and pro- 
tracted cry, with restlessness, pressing the head on the pillows or breast of 
the nurse, and frequent carrying of the finger to the ear, indicate otalgia. 

Circulatory System. 

In all ages and countries the pulse has been considered an important 
symptom, both in diagnosis and prognosis. It aids the practitioner in deter- 
mining, approximately, not only the character, but the gravity, of diseases. It 
is somewhat remarkable, from the importance which is attached to the pulse 
in medical practice, that its natural frequency and its character in infancy are 
not more accurately known. It is true that eminent observers, as Trousseau 
and Yalleix, have published statistics relating to the infantile pulse in healthy 
but these statistics disagree, and therefore do not afford a reliable standard 
with which to compare the pulse in disease. Moreover, some published 
statistics of the pulse possess but little value from the small number of 
observations ; some from the fact that records of the infantile pulse are 
grouped with those of older children ; and others because the state of the 
infant as regards its activity or emotions is not mentioned. 

Pulse in Health. — It is not easy to collect statistics of the pulse during 
the period of infancy which are entirely free from error, since slight derange- 
ments of the system in the infant frequently occur which are not manifested 
by any marked symptoms, but which produce acceleration of pulse. In 
collecting the following statistics sources of error, so far as possible, were 
avoided. 

The movements of the heart commonly begin about one-eighth of a min- 
ute after birth. They are at first slow, the ventricular contractions not 



DIAGNOSIS OF INFANTILE DISEASES. 



75 



numbering more than eight or ten by the close of the first quarter minute. 
In the second quarter the cries are vigorous, and the pulse now is rapidly 
accelerated, rising commonly above 120, and sometimes above 160, beats per 
minute. In fifty-seven observations of the pulse in healthy infants during 
the first half hour of life, after the first quarter of a minute I found that the 
extremes, with one exception, were 104 and 164 — average, 139. The statis- 
tics of the normal pulse in infancy have been stated in a preceding chapter. 



Pulse din 


'ing or after 


Active Movements or Great Mental Excitement. 




Age. 




First week. 


Close of first 
week to close 
of first month. 


Close of first to 

close of third 

month. 


Close of third 

to close of sixth 

month. 


Close of sixth 

month to close 

of first year. 




140 
160 
140 
152 


162 
156 
140 
152 


176 
152 
158 
144 
152 
180 


132 
148 
148 
144 
156 
156 


132 
144 
152 

182 
198 
160 


Extremes . . 
Mean .... 


140-160 
148 


146-162 
152 


144-180 
160 


132-156 
147 


132-198 
156 



It is seen by the above table that by active exercise or great mental excite- 
ment the pulse may become as rapid as in grave diseases. There is greater 
acceleration of pulse from the emotions and from exercise in feeble than in 
robust children. Obviously, in order to determine to what extent the pulse 
is accelerated in disease it is necessary that it should be counted during a 
state of quietude. As the age increases it is less and less influenced by the 
emotions and physical exertion ; still, during the whole period of childhood 
such influences do have more or less effect on its frequency. 

Pulse in Disease.— Febrile and inflammatory diseases produce greater 
acceleration of pulse in early life than in maturity. Diseases or derangements 
of system, particularly those of the digestive organs, which do not materially 
affect the pulse in the adult, often cause acceleration of it in children. The 
febrile pulse of early life usually has exacerbations in its frequency. These 
commonly occur in the latter part of the day. Distinct and more or less reg- 
ular febrile exacerbations and remissions are common in several diseases of 
early life, some of which are serious, while others involve little danger. 
Among these diseases may be mentioned difficult dentition, intestinal worms, 
incipient meningitis, and constipation. An intermittent and irregular pulse 
is common in fully-developed meningitis and certain other severe organic 
diseases of the encephalon. It may be due also to disease of the heart, and 
it also occurs in some children from temporary disturbance of the digestive 
function. The pulse is slow in compression of the brain and in sclerema of 
the new-born. 

Animal Heat. 

The importance of thermometric observations as an aid to the diagnosis 
of children's diseases is within a few years more fully recognized. Two 
diseases may at their commencement have very similar symptoms, except in 
the temperature, which may vary greatly. In such cases the thermometer is 



76 



INFANCY AND CHILDHOOD. 



of great value as an aid in differential diagnosis. In a preceding chapter we 
have given the statistics relating to the temperature of infants in health. 
We may add that in 33 infants under the age of seven days A. Roger found 
the average temperature to be 98.6° F. 

Elevation of temperature above the normal is regarded by physicians as 
an important evidence of disease. But a rise in temperature of three or four 
degrees frequently occurs in young children from slight causes, as indigestion, 
constipation, and mental excitement. Those physicians who have given little 
attention to this subject will probably be surprised by the history of the fol- 
lowing case : 

Case. — A female child in its second year, wet-nursed by its mother in the New 
York Infant Asylum, during my attendance in 1894, and carefully attended by the 
resident physicians, Drs. A. and E. Parry, had a mild intestinal catarrh, but not so 
as to appreciably affect the temperature. But the infant was extremely emotional. 
The sudden entrance of a stranger, slamming the door, the attempt of a stranger 
to hold it, caused the high and transient elevations shown in the following chart : 

Fig. 3. 



t 



M 



:\ 



S3 



era 



\M 



M 



A physician examining this case would probably make a serious error in 
diagnosis and prognosis if he did not remain long enough to witness the 
decline of the fever. 

It is very important that the normal temperature be preserved during 
infancy. In bottle-fed infants a continued temperature at or below 97° 
indicates a fatal termination. In the large number of foundlings in the New 
York Foundling Asylum, most of whom are necessarily deprived of breast- 
milk, I have not yet seen one live more than a few weeks whose temper- 
ature remained below 97°. Young children, therefore, whose temperature 
continues subnormal notwithstanding the use of abundant well-selected food, 
alcoholic stimulation, and warm external appliances should be placed in an 
incubator. On the other hand, I have seen an infant with a temperature of 
90° in the New York Infant Asylum, placed in the incubator and wet-nursed, 
survive. It is true that the wet-nursing was a very important part of the 
treatment. 

An incubator designed by Dr. S. Marx of New York possesses the merits 
of simplicity of construction, ease of management, and moderate cost. The 
apparatus consists of a wooden box 30 inches long, 16 inches wide, and 24 
inches in height, with a lining of non-conducting hair-felt f inch thick, over 
which is a layer of sheet zinc, the top of the box being supplied with a slid- 
ing cover of glass. Within the box is suspended a wire cradle designed to 
hold the infant, hanging about 2 inches from the top of the box and being 9 
inches in depth. The heat is generated by means of a copper boiler situated 
on a platform which projects out from the bottom of the box at one end. 
The boiler is connected with the box by means of a coil of lead pipe passing 
through the bottom of the box and imbedded in sterilized gravel. The water 



DIAGNOSIS OF INFANTILE DISEASES. 
Fig. 4. 



77 




Fig. 5. 




in the boiler is heated by a Bunsen burner, and the steam passing through 
the pipe heats the gravel, above which are valves for the ingress of cold air. 



78 INFANCY AND CHILDHOOD. 

which, becoming heated, rises and circulates in and around the cradle, and 
finds a vent in the valves at the top of the box. 

The heat is measured by a long, delicate thermometer fastened to the 
upper and inner side of the cradle, and is regulated by an electrical thermo- 
stat of exceeding delicacy fastened to the outer end. At the approach of 
the maximum or minimum heat-limit the thermostat causes the ringing of a 
bell, which ceases only upon the attendance of the person in charge, ensuring 
the watchfulness which is of so much importance. 

The thermostat receives its power from two dry-cell batteries placed on 
the boiler platform and protected by a brass box lined with felt. 

Digestive System. 

Inspection of the buccal and faucial surfaces discloses some of the most 
frequent local diseases of infancy, as the various forms of stomatitis, and 
others which, though not frequent, involve great danger, as gangrene of the 
mouth, diphtheria, and retro-pharyngeal abscess. Inspection of the tongue 
aids in determining in many cases whether the disease be pursuing a favor- 
able course or has become asthenic and is exhausting the vital powers. 

Febrile movements, even when slight, give rise to coating of the tongue 
and intumescence and distinctness of its follicles. The eruptive fevers are 
attended by changes upon the buccal and faucial surfaces which possess 
diagnostic and prognostic value. Hyperasmia of these surfaces appears early 
in rubeola and scarlatina prior to those phenomena which are justly regarded 
as pathognomonic. It is therefore often an important sign in the initial period 
of these diseases when the diagnosis is obscure. The appearance of the 
fauces in diphtheria and croup, indicating not only the nature of the disease, 
but its gravity, need only be referred to in this connection. 

Inspection of the buccal and faucial surfaces sometimes enables us to 
form a probable opinion in reference to the nature of diseases which are 
seated in other parts. In the infant protracted stomatitis is a common 
accompaniment of chronic diarrhoea, and it indicates its inflammatory 
nature. 

Vomiting is more frequent in infancy than in childhood, and in either 
period than in adult life. It is common in cerebral affections, and is one of 
the first symptoms of scarlet fever, and is not uncommon, though less fre- 
quent, in the commencement of other essential fevers and of acute inflam- 
mations. It is a symptom of indigestion, entero-colitis, cholera infantum, 
and intussusception; it is common also after the paroxysmal cough of per- 
tussis, and not infrequent in the bronchial inflammations of young infants. 

Intestinal gas is in part secreted or exhaled from the mucous membrane, 
as the experiments of Hunter and others have shown, and is in part the 
product of chemical changes in the food. A certain amount of gas in the 
intestines is normal ; it subserves a useful purpose. An abnormal amount 
of it is common in various diseases, as indigestion, chronic entero-colitis, peri- 
tonitis, typhoid fever. It is a frequent cause of gastralgia and enteralgia in 
the infant. In scrofulous or feeble infants with impaired muscular tonicity 
and faulty digestion the abdomen is often habitually more or less distended 
with gas. which does not, under such circumstances, give rise to pain or other 
local symptoms ; it has significance as showing the general condition of the 
child. 

In the rachitic, whose thorax is compressed and liver often enlarged, 
while the vertebral column is shortened, the abdomen is commonly pro- 
tuberant. In feeble children, usually more or less rachitic, whose lungs 
are seldom fully inflated and whose chests are consequently depressed, the 



DIAGNOSIS OF INFANTILE DISEASES. 



79 



Fig. 6. 



abdomen is also prominent. The accompanying woodcut represents one of 
these cases presented for treatment at the Out-door Department at Bellevue. 

In feeble children who have suffered from 
repeated and protracted attacks of bronchitis, 
and whose chest-walls are consequently de- 
pressed, a similar abdominal prominence occurs. 

Retraction of the abdominal walls is common 
in meningitis and in many exhausting diseases. 
Tenesmus is a symptom of intussusception in 
the infant and of colitis in children. 

Much light is thrown on the character of 
intestinal diseases by the appearance of the 
stools. Muco-sanguineous stools accompanied 
by fever are a sign of colitis. Stools contain- 
ing unmixed blood and not accompanied by 
fever may result from a rectal polypus and from 
purpura hemorrhagica. Scanty evacuations of 
blood, with obstinate constipation, are a symp- 
tom of intussusception in infants. 

The alvine discharges of infants often present 
a green color ; sometimes they have the normal 
yellow hue when passed from the bowels, but 
become green on exposure to the air or from 
reaction of the urine. By the microscope the 
green coloring matter is seen to occur in small, 
irregular masses. This green substance has been 

supposed to be bile. I am convinced that as it occurs in the stools of the 
infant it is commonly produced by the action of the intestinal secretions on 
the contents of the intestines ; for I have often noticed that the contents in 
and above the jejunum were yellow, while in and below the ileum their color 
was green. Probably the green color is due to the formation of biliverdin 
from the bile which is mixed with the fecal matter. 

The green hue may occur from very different causes. It may be due to 
overfeeding, to the action of cold, to irritating ingesta, to inflammation, etc. ; 
it may be transient, subsiding within a day or two, or it may continue several 
days. All infants at times have green evacuations, even when they appear 
in good health. 

In the commencement of a large proportion of diarrhoeal maladies in 
infancy the stools give an acid reaction to litmus-paper. This acid, if in 
considerable quantity, is irritating, increasing the peristaltic movements of 
the intestines and the functional activity of the intestinal follicles, causing 
erythema of the skin around the anus, and reacting upon and intensifying 
the intestinal disease. 

The presence of intestinal worms and the species may be ascertained by 
microscopic examination of the stools of a child which is affected with these 
entozoa. The stools contain ova, which differ in size and shape according to 
the species of worm. 




Nervous System. 

Pain. — This symptom affords important aid to the physician in determin- 
ing the seat and nature of the diseases of children. Pain in the head may 
occur in them from coryza involving the frontal sinuses, or from febrile 
movement in the commencement of an essential fever, or from inflammation 
of one of the organs of the trunk. Produced by such a cause, it abates in 



80 INFANCY AND CHILDHOOD. 

two or three days. If it be protracted, whether constant or intermittent, it 
is in many cases not neuralgic, as it so often is in the adult, but is due to 
organic disease of the brain or meninges. Complaint, therefore, of headache 
in a child, without any apparent general cause or local cause external to the 
cranium, should awaken solicitude, and if it be protracted the physician should 
examine carefully in reference to the presence of a cerebral or meningeal dis- 
ease. Mild frontal headache continuing for weeks or months is neuralgic 
and due to anaemia. It is increased by pressure over the occiput and upper 
cervical vertebrae. 

Grave thoracic or abdominal inflammations in the adult are almost always 
attended by a corresponding amount of pain and tenderness, but in children 
these symptoms are often absent, or when present are frequently not commen- 
surate with the amount of disease. Thus, entero-colitis of nursing infants is, 
in a large proportion of instances, almost free from these symptoms. 

Pain in the chest or abdomen, occasional or constant, continuing for weeks 
or months, with fever, and unattended by thoracic or abdominal disease, indi- 
cates caries of the vertebrae. Its most common seat is the epigastric, umbili- 
cal, or hypochondriac region. It is a neuralgia due to irritation of the 
sensitive root of one or more of the spinal nerves. It is a very important 
symptom to the diagnostician, showing the nature of the disease, which in its 
incipiency is so obscure. Pain in the leg, especially the inside of the knee, 
is of a similar character, indicating disease of the hip-joint. 

Children with certain acute febrile and inflammatory diseases sometimes 
have hyperaesthesia of portions of the surface ; it is especially marked upon 
the anterior aspect of the trunk. The physician might be misled into the 
belief that the tenderness occurred over the seat of the disease and indicated 
an inflammation ; but the pain of hyperaesthesia can be diagnosticated from 
that of inflammation by the fact that it is so extensive, is less on firm than 
light pressure, and is especially observed upon the inner surface of the thighs. 
The symptoms pertaining to the nervous system occurring in the various dis- 
eases treated of in this book will be fully described in connection with those 
diseases, and therefore need not detain us in this connection. 



CHAPTER XI. 

THERAPEUTICS. 

The young practitioner is often perplexed in deciding exactly what dose 
of the stronger and more dangerous medicinal agents to prescribe for a child. 
A practical rule, which holds good for many medicines, has been proposed by 
Dr. Cowling, as follows : " The proportional dose for any age under adult life 
is represented by the number of the following birthday divided by twenty- 
four." This rule is inadmissible for infants under the age of six months, but 
will apply for those that are older for the use of a large number of medicines. 
Another rule, proposed by another British physician, Professor Clarke, is based 
on differences in weight of children and adults : The adult dose is represented 
by 150. The dose of a child is determined by dividing its weight in pounds 
by 150. But it is an interesting fact, and one of practical importance, that 
children bear and often require, in order to obtain the desired effect, a much 
larger proportionate dose of certain agents than adults. This is partly attrib- 
utable to the active elimination in childhood. Belladonna is notably one of 



THERAPEUTICS. 81 

the agents which children tolerate, and it may be added that some children 
can take a much larger dose of it than others without producing the physio- 
logical effects. Thus, recently I increased gradually the tincture of bella- 
donna to twelve drops for a child of four years without producing the usual 
efflorescence ; and Farquharson says, " The dose .... I have pushed in a 
child of ten suffering from incontinence of urine to fgij (British Pharmacop.) 
with good effect and the development of mild forms of physiological disturb- 
ance.'" Arsenic is also better tolerated by children than adults. An infant 
of six months can take two-drop doses of Fowler's solution three times daily 
without ill effect. Prussic acid, strychina, iron, ipecacuanha, and alcohol are 
also required in larger proportionate doses in childhood than is indicated by 
the rule either of Dr. Cowling or Professor Clarke. 

When practicable, medicines should be given in the liquid form. Those 
not soluble may often be given in suspension in some vehicle which in great 
part disguises the taste. A good vehicle for the bitter vegetables, as the salts 
of quinia. is the elixir adjuvans of Caswell and Hazard. 

The elixir adjuvans may also be advantageously employed in the adminis- 
tration of many other medicines apart from those which are repulsive on 
account of their bitterness. It holds them in suspension, so that if they have 
a greater specific gravity than the elixir, it is necessary to shake the bottle 
thoroughly before using it. The elixir taraxaci comp. is another good vehi- 
cle for the bitter vegetables, but perhaps their bitterness, especially that of 
quinine, is more effectually disguised by the syr. yerbse santae comp. than 
by any other vehicle. I am sure, from many observations, that unpleasant 
doses are liable to be wasted to a greater or less extent, and the repug- 
nance of children to medicines employed has induced many a parent to seek 
other and less disagreeable modes of treatment. Chemistry has greatly aided 
the therapeutics of childhood, in that it has enabled us in so many instances 
to prescribe the active principles in place of the large, nauseous doses formerly 
employed. 
6 



PART II. 



DISEASES OF THE NEWLY-BORN. 



CHAPTER I 



Fig. 7. 



MALFORMATIONS. 

The malformations, both of internal and external organs, are numerous, 
and they require attention according to their seat and gravity. 

Acrania. 

In this malformation the bones and integuments forming the cranial arch 
are absent. In extreme cases the cranial arch, part of the neck, the brain, 
and the medulla oblongata are lacking. A 
vascular mass lies on the exposed base of 
the skull, often resembling the placenta in 
appearance. It consists of connective tis- 
sue in addition to the vessels. It is the 
representative of the cerebral meninges, 
and is continuous below with the spinal 
meninges. Its smooth surface is the ana- 
logue of the arachnoid. 

The sensation which is imparted to the 
finger of the accoucheur pressed upon it is very 
similar to that produced by a placenta. In 
some specimens small portions of cerebral mat- 
ter are found among the vessels of this tumor, 
but they are so disconnected and isolated that 
they do not perform in any way the functions 
of a brain. Occasionally the vascular tumor is absent and the medulla — or, if this 
be absent, the upper extremity of the spine — is exposed. 

The absence of the brain and cranial arch gives a remarkable appearance. 
The frontal, parietal, and occipital bones are absent, except those portions 
which are near the base of the cranium. These portions are very thick and 
closely united, as if there were the usual amount of osseous substance, but 
instead of expanding into the arch it had collected in an irregular mass at 
the base of the cranium. The eyes are prominent, the neck thick and short, 
while the body and limbs are ordinarily well developed. The physiognomy 
has a frog-like appearance. Those portions of the cranial nerves which lie 
without the cranium are well developed, although the intracranial portions 
are absent. In this anomaly of acrania and anencephalus a twin is often 
present which in some manner has interfered with the normal development 
of the foetus. 

82 




MALFORMATIONS. 83 

Symptoms. — If the medulla be absent, of course viability is impossible. 
If it be present, respiration may occur for a time, but is irregular. The 
monster may be made to cry, but the cry is a reflex phenomenon resembling 
a sob or hiccough. It may nurse, its digestive function is well performed, 
and regular urinary and fecal evacuations occur. There is a tendency in such 
monsters to convulsions. Blowing upon them and pressure upon the project- 
ing medulla, if this be present, frequently produce this result. 

Prognosis. — Fortunately, non-viability or speedy death is the result. If 
the medulla be present and respiration and circulation be established, never- 
theless death usually results within two or three days, and with scarcely an 
exception within ten days. Convulsions sooner or later supervene, ending in 
fatal coma. 

Deficiencies of the brain are of various grades of incompleteness between 
the normal and absent brain. Portions of the brain may be absent or rudi- 
mentary, while the remainder of the organ has its normal development. The 
deficiencies are usually in the cerebral hemispheres, while the base of the 
brain, which is important for the maintenance of life, is perfect. Both hemi- 
spheres may be absent, or one absent while the other is complete or small and 
rudimentary. Incompleteness of the brain may be manifested by the small 
size of the cranium and the retreating forehead, but occasionally the cranium 
has its normal shape and size, on account of an increase in the cerebro-spinal 
fluid proportionate to the deficiency in the cerebral development. 

Such a case was under observation in the Nursery and Child's Hospital in 1862. 
She took the breast and received food when placed in her mouth, but without appar- 
ent relish. She was supposed for a time to be blind, as she was apparently uncon- 
scious of objects around her. There was a total absence of intellectual manifesta- 
tions. The size and shape of the head did not differ from the normal, but the frontal 
bone lay a little lower than the parietal. She died of entero-colitis at the age of ten 
months, and at the autopsy a sac containing about three-fourths of a pint of nearly 
transparent cerebro-spinal liquid occupied the site of the cerebral hemispheres. 
Rudimentary hemispheres were found constituting a part of the walls of the sac. 
The weight of the brain after being a few days in dilute alcohol was 6J ounces. 
In this case the fluid was nearly sufficient to compensate for the lack of brain- 
substance. 

Symptoms. — Since in cases of imperfect brain in which life is preserved 
the arrest of development is usually in the cerebral hemispheres, the symp- 
toms which indicate the deficiency relate chiefly to the degree of mental 
endowment. If the hemispheres are partially developed, there is a degree 
of intelligence proportionate to the amount of the cerebral substance present. 
If the arrest of development be on one side, there may be no appreciable lack 
of intelligence or mental activity, since one hemisphere may perform the 
functions of both. 

Prognosis. — Life depends on the seat of the arrested development. If 
the cerebral hemispheres be deficient, the child may live and thrive, though 
idiotic ; but if the arrest of development be at the base of the brain, which 
controls the functions of animal life and gives origin to nerves which are 
essential to the physical well-being, life is uncertain and probably will be 
short. It is evident that therapeutic measures cannot remedy a congenital 
deficiency in the brain, but the patient, philanthropic teacher can impart some 
instruction to the idiotic, and occasionally improve in a measure their lament- 
able condition. 

Meningocele, Encephalocele, Hydrencephalocele. 

An opening exists at some point in the skull, through which the meninges. 
or meninges with brain-substance, protrude. The deficiency is congenital, and 



84 



DISEASES OF THE NEWLY-BORN. 



the tumor exists at birth or is noticed soon after. It is termed a meningocele 
if only meninges protrude ; an encephalocele if it contain brain-substance in 
addition to the meninges ; and a hydrencephalocele if, in addition to the brain- 
substance, the mass contain liquid in its interior. 

The most frequent site of these tumors is the occiput, where the protru- 
sion occurs from an opening in or at the edge of the occipital bone. The next 
most frequent location is the naso-frontal region. Rarely they occur upon 
the temporal, parietal, and basilar portions of the skull. Ordinarily, the open- 
ing in the occipital bone through which the protrusion takes place is at the 
median line, or near it, anterior or posterior to the occipital protuberance. 
The opening, if in the anterior part of the occipital bone, may extend to the 
fontanel ; if in the posterior part, it may extend to the foramen magnum. It 
may connect posteriorly through the foramen magnum with the cleft of a 
spina bifida. If the opening of the occipital bone be large, the tumor is also 

Fig. 8. 




usually large. Prescott Hewitt cites a case in which it extended to the 
loins ; but so large a mass consists mostly of liquid and is rare. An occipital 
encephalocele contains brain-substance from the cerebellum or posterior cere- 
bral lobes or from both. If the tumor upon the occiput be a hydrencephalo- 
cele, the liquid is from the posterior cornu of a distended lateral ventricle or 
from a distended aad dropsical fourth ventricle, and it occupies the interior 
of the tumor, the brain-substance surrounding it. 

If the tumor be in the frontal region, the protrusion usually occurs between 
the cribriform plate of the ethmoid bone and the frontal bone, and it appears 
externally between the nasal and the frontal bones. Exceptionally, the point 
of protrusion is between the lateral halves of the frontal bone. The anterior 
lobe or lobes of the cerebrum protrude in an encephalocele in this location ; 
if the tumor be a hydrencephalocele, the liquid is derived from the anterior 
cornua of the lateral ventricles. As a rule the frontal are smaller than the 
occipital tumors, and the skin covering them is more frequently red and 
vascular, so as to present the appearance of vascular tumors. 

Exceptionally, the protrusion occurs from a fontanel or from the line of 
one of the sutures, so that it is seated upon the side of the skull. Cases are 
also on record in which the opening existed between the ethmoid and sphe- 
noid bones, through the sphenoid, or between the sphenoid and its greater 
wing. Tumors in this location appear in the pharynx or mouth, or enter an 
orbit, displacing the eye, or protrude through the spheno-maxillary fissure. 



MALFORMA TIONS. 8 5 

The tumor having this site is usually an encephalocele or hydrencephaloceie, 
the meningocele being rare. Its walls consist of skin, dura mater, and arach- 
noid, with intervening connective tissue. If the protrusion be at the base 
of the brain, of course the external covering of skin is lacking. In other 
locations the skin constitutes the external coat, and it may be tense and scant- 
ily covered with hair, or red and vascular. The interior of the sac is lined 
by the arachnoid and dura mater. These tumors, whatever the exact charac- 
ter of their interior, can be more or less reduced by compression, with a return 
of a part of their contents into the cranial cavity ; but such compression 
usually produces cerebral symptoms, as stupor or fretfulness, vomiting, and 
strabismus. 

Diagnosis. — The following characteristics of the three forms of these 
tumors aid in their differential diagnosis : 

Men ingocele. Encephalocele. Hydrencephaloceie. 

Small at first, and re- Small, base wide, no Tumor usually large, 

maining either small or of fluctuation, opaque, or often pendulous, and its 
moderate size, fluctuation sometimes translucent at surface lobulated, peduncu- 
distinct, pedunculated, the apex, distinct pulsa- lated, fluctuating ; portions 
translucent, no pulsation, tion, enlargement by forced translucent; pulsation ab- 
tense on forced expiration, expiration, partly reduci- sent or rare. It is seldom 
reducible. ble, cerebral symptoms oc- affected by pressure, and 

curring from compression, the patient is likely to be 
microcephalic from the es- 
cape of brain-substance ex- 
ternal to the cranium. 

These protrusions have been mistaken for various cysts, as, cephalhema- 
toma, serous and sebaceous cysts, abscesses, vascular growths, and polypi. 
The fact that such errors in diagnosis have been made by various surgeons 
shows the importance of a thorough and careful examination before operative 
measures are employed. 

Prognosis. — Most patients with this deformity die in a few weeks or 
months. The prognosis depends on the size of the aperture and the amount 
of protrusion. It is most unfavorable in hydrencephaloceie, which is usu- 
ally attended by deficiency of brain within the cranium, sometimes to such 
an extent that the patient is microcephalic and early death is unavoidable. 
The hydrencephalic tumor is very liable to grow, and, after a time, rupture, 
causing immediate death in convulsions or collapse. In meningocele, if the 
aperture be small, the tumor may remain small, become isolated from the 
cranial cavity, and the patient may live for years. But of the three forms 
of the tumors, encephalocele is regarded as the most favorable, since it is 
usually small, and patients with it not infrequently live many years. The 
prognosis in these tumors is very similar to that in spina bifida, which varies 
according to size of the aperture and the amount and character of the pro- 
trusion. 

Treatment. — Those who have had experience with these tumors concur 
for the most part in the opinion that surgical interference should not be 
resorted to unless rupture be imminent. The mass should be protected from 
abrasion, and that degree of pressure should be employed which can be toler- 
ated without producing cerebral symptoms. It is proper to draw off the 
liquid of a meningocele if it be distended and likely to rupture, and the tap- 
ping may be repeated, with, exceptionally, the result of a cure or of render- 
ing the tumor stationary. Mr. Holmes has injected the tumor with two 
drachms of a mixture consisting of one part of tincture of iodine and two 
of water, allowing it to remain ; and Mr. Annandale has ligatured the mass 
in one instance and effected a cure. In encephalocele and hydrencephaloceie 



86 



DISEASES OF THE NEWLY-BORN. 




support and moderate pressure should be employed, and in the latter some of 
the liquid should be removed by a small trocar if rupture be threatening. 

Spina bifida is one of the most common of malformations. The term 
" spina bifida ;; is applied to a hernia of the spinal meninges, which produces 
a rounded tumor situated posteriorly over the spine in the median line. It is 
due to the congenital absence or incompleteness of one or more of the arches 
of the vertebras. In exceptional instances the arch is complete at birth ; but 
the lateral portions separate and are pressed outward during the first weeks 
of life. The tumor contains cerebro-spinal fluid, and unless it be small and 
its walls unusually thick fluctuation may be detected in it. When the child 
cries the tumor enlarges, and it is reduced by compression, the fluid re-enter- 
ing the spinal canal. If the tumor be large, its complete subsidence by pressure 
sometimes produces dangerous cerebral symptoms. It often coexists with its 

analogue, hydrocephalus. If we 
jr IG 9 compress the hydrocephalic head, 

the spinal tumor enlarges, and vice 
versa. Club-foot is another not in- 
frequent complication. 

In the case which is represented in 
the accompanying wood-cut (Fig. 9) 
hydrocephalus, spina bifida, and club- 
foot coexisted. The child was brought 
to the children's class in the Out-door 
Department at Bellevue, and after a 
few visits I lost sight of it. It prob- 
ably died soon after, since the tumor, 
over which the cuticle was wanting, 
presented a deep-red appearance as 
if inflamed, so that ulceration and 
escape of the fluid seemed near at 
hand. 

There is ordinarily but one spina 
bifida, the common seat of which is 
the lumbar region, but occasionally two or more are present. If the aperture 
through which the tumor protrudes be small, it is usually pedunculated, but 
if large it is sessile. In some patients it is covered with skin, which may be 
normal or somewhat indurated ; in others the skin is absent over the entire 
tumor or its most prominent part, and the dura mater or the connective tissue 
lying directly over the dura mater is exposed, and is liable to inflammation 
from friction. If the walls of the tumor be thin, the liquid may transude in 
drops, and they are liable to give way by ulceration or rupture. Sudden 
escape of the liquid and collapse of the spina bifida involve great danger, for 
convulsions, coma, and death are the common result. 

The relation of the spinal cord or nerves, or of the cauda equina, to the 
tumor is a matter of great importance. In many patients the adjacent por- 
tion of the cord or cauda equina is deflected through the aperture, and lies 
against the anterior of the sac. Spinal nerves also not infrequently lie within 
the sac, some returning into the spinal canal, and others passing through the 
walls of the sac to their points of distribution. Those which are deflected 
into the tumor and return into the canal obviously lie lowest. In cases with 
a small aperture or small tumor or a narrow and long peduncle neither the 
cord, cauda equina, nor nerves lie within the sac. 

It is important to the practitioner to bear in mind that in all probability, unless 
under the favorable anatomical circumstances stated above, the sac contains nervous 
elements. In rare instances the liquid, instead of lying externally to the cord, lies 



MALFORMA TIONS. 8 7 

within its central canal. The substance of the cord then becomes distended, and it 
encloses the liquid like a delicate sac, just as the hemispheres of the brain are un- 
folded and expanded in the common form of congenital hydrocephalus. As might 
be expected from the anatomical characters of the more serious forms of spina bifida, 
paralysis, more or less complete, of the vesical and rectal muscular fibres and para- 
plegia sometimes occur, in which event the fatal issue is probably not far distant. 

The diagnosis is easy in ordinary cases. The congenital nature of the 
tumor and the bony edge of the aperture, appreciable to the touch, suffice in 
ordinary cases to establish the diagnosis. The diminution of the tumor by 
pressure, and its enlargement when the child cries, are important diagnostic 
signs. 

There are various lumbo-sacral tumors located in the median line from which 
it is important that spina bifida should be diagnosticated. Sometimes a cyst occurs 
in this situation which was originally a spina bifida, but obliteration of the canal 
in the pedicle occurred, just as the canal connecting a hydrocele with the abdom- 
inal cavity closes. Solid congenital tumors sometimes also grow in the same situa- 
tion, among which, as most common, may be mentioned fatty tumors and tumors 
containing foetal remains. The most common seat of tumors which enclose foetal 
remains is at the point where spina bifida ordinarily occurs. Physicians have erred 
in mistaking these tumors, as well as those which consist of fat, for spina bifida ; 
but a mistake in diagnosis can only occur through haste or carelessness of exami- 
nation. 

The prognosis is unfavorable in most instances. Ordinarily the tumor 
increases slowly, and finally the sac gives way by ulceration or rupture ; the 
liquid escapes, and death occurs in convulsions and coma ; or, if the escape 
of the liquid be prevented by pressure and the aperture closes, a second rup- 
ture is probable, with a fatal result. In other cases the tumor may not rup- 
ture, but the cord is softened or it is injured by being bent, so that paraplegia 
results, and death after a time occurs in a state of emaciation. Rarely the 
tumor may shrivel by absorption of the liquid, and the disease is cured, or 
so nearly cured that it gives no inconvenience and the patient lives for years. 
In other rare instances the tumor may remain without any material change 
and without giving rise to symptoms. The spina bifida being small and cov- 
ered with skin, and the aperture leading from it into the spinal canal being 
also small, the patient lives through the natural period of life with little 
inconvenience. 

The treatment can be limited to no fixed rule. In the most favorable 
cases, in which no symptoms occur and there is no indication that the tumor 
will undergo any unfavorable change, surgical treatment is not required, 
except the application of a soft pad to support the tumor, so as to prevent its 
injury by friction. Indications which justify active surgical interference are 
growth of tumor, absence of skin from it, with tension of the parietes, so 
that an early rupture is inevitable, and the occurrence of dangerous nervous 
symptoms, as convulsions or paraplegia. 

From the nature of spina bifida it is evident that operations upon it must 
be conducted with caution. The usual presence of the spinal cord in the 
pedicle and in the sac forbids ligation and excision, and renders hazardous 
attempts to obliterate the sac by producing inflammation within it. A safe 
mode of treatment, but not the most efficient, is to puncture the sac and 
withdraw a portion of the liquid by a grooved needle or hypodermic syringe 
with antiseptic precautions. A soft pad should then be applied to produce 
gentle compression. If no unfavorable symptoms occur, the puncture may 
be repeated after a day or two. This operation is not devoid of danger. 
for the removal of the liquid, if carried beyond a certain point, may produce 
dangerous nervous symptoms, especially convulsions. In performing the 
operation the puncture should never be made in the median line, on account 



88 DISEASES OF THE XEWLY-JBORX. 

of the danger of wounding the cord, which lies against the median portion 
of the sac. The veins, also, should be avoided. 

Another mode of treatment is by iodine injections. They are preferable 
to other methods if the neck be long and pedunculated, so as to be easily 
compressed. If the tumor be sessile and the aperture into the spinal canal 
be free, these injections involve great danger, and are not to be recommended ; 
for more or less of the solution will inevitably enter the spinal canal and 
give rise to spinal meningitis. 

Iodine injections have been employed with success by Professor Brainard of 
Chicago, who states that he " perfectly and permanently cured " three of seven 
cases : and by Telpeau of Paris, by whose method five in ten operations were suc- 
cessful : and by many others. Professor Brainard withdrew some of the liquid con- 
tents, and then injected half an ounce of water containing 2 J grains of iodine and 
7 j grains of iodide of potassium. In a few seconds this was allowed to flow out, 
and the sac was then washed out with tepid water. Then a portion of the cerebro- 
spinal fluid, which had been kept warm, was returned into the sac. When he had 
withdrawn six ounces of this fluid he returned two ounces. In employing the 
iodine or any other irritating injection it is necessary to compress the pedicle, so 
that the liquid does not enter the spinal canal. Velpeau employed one part of 
iodine, one of iodide of potassium, and ten of distilled water. 

M. Debont recommends the evacuation of only a little of the fluid, and the injec- 
tion of two or three drops of the tincture of iodine diluted with an equal quantity 
of water. T. Smith, 1 by the injection of one drop of the tincture, produced an 
amount of inflammation which nearly obliterated the sac. Since statistics show so 
good a result of iodine injections, this mode of treatment seems preferable to any 
other for certain cases, and as one drop has produced general inflammation of the 
sac and nearly obliterated it, it seems safest and best to begin with so small a 
quantity. 

If there be reason to believe, from the small size of the orifice and other 
anatomical characters, that neither the cord, caucla equina, nor any of the 
spinal nerves lie within the sac. it may be thought best to remove the tumor. 
It has. indeed, been proposed to open the tumor, immersed under warm water, 
sufficiently to observe the relation of the nervous elements, and to press them 
back gently into the canal if they lie within the sac. If it be decided to 
remove the spina bifida, a clamp or elastic band is placed around the pedicle 
so snugly as to cause firm adhesion of the walls of the pedicle, and excite 
sufficient inflammation in them to produce agglutination, but without causing 
strangulation or suppuration. After a time, perhaps two or three days, 
when it is evident that agglutination has occurred from the fact that the 
liquid cannot be returned within the spinal canal by compressing the sac, the 
tumor may be removed by the knife or ecraseur. 

Statistics do not show so favorable a result of this operation as of the iodine 
treatment, and the reason is obvious, for it is only in exceptional cases that the 
tumor can be removed without injury to the nervous tissue, and incision of a portion 
of the cord or of important nerves either produces death or a condition to which 
death would be a relief. 

Spina bifida has also been treated by opening the sac on its side, pressing 
back the spinal cord or its nerves into the spinal canal, uniting the edges of 
the wound, and then applying pressure to prevent protrusion, but the result 
has not been favorable. Treatment by simple puncture, followed by com- 
pression, and if it fail, as it probably will, the cautious use of iodine injec- 
tions, is the preferable mode of treating ordinary cases of spina bifida which 
require surgical interference. 

1 Holmes's Surg. Dis. of Children. 



MALFORMA TIOXS. 89 

Congenital Abnormalities in the Circulatory System. 

The position of the heart is rarely abnormal, and the most common mal- 
position is its location on the right side of the chest (dextro-cardia). This 
occurs with or without misplacement of other organs. In cases of dextro- 
cardia the liver usually, says Nieineyer, occupies the left hypochondrium, 
and the spleen the right. In this misplacement of the heart the aorta ordi- 
narily crosses the right bronchus and passes along the right side of the ver- 
tebrae, but occasionally it crosses the spine and lies in its usual position on 
the left side of the vertebrae. The heart in this malposition is sometimes 
imperfect and sometimes well formed. In mesocardia the heart is situated 
nearer the median line than usual, corresponding in this respect with the 
position which it occupies in the first months of foetal life. A rare malposi- 
tion is the location of the heart outside the thoracic cavity (ectocardia extra- 
thoracica) — a condition accompanied by, and perhaps due to, deficiency in 
the sternum or sternum and ribs. In other instances equally rare a part 
of the diaphragm has been deficient, and the heart has lain in the abdomen ; 
and in other instances still it has been located at the base of the neck. 
Breschet and others have cited examples of these various forms of ectopia 
cordis. 

Symptoms — Prognosis. — If the heart be well formed and complete, its 
abnormal position within the thorax may not give rise to symptoms, and is 
not incompatible with prolonged life. If it be located without the thoracic 
cavity or be within the cavity and be defective, early death is probable. 

MnJformation of the heart occurs — 1st, from arrested development early 
in fcetal life, so that the organ remains rudimentary ; 2d, from arrested 
development at a more advanced stage, when the cavities, septa, and ves- 
sels, though incomplete, are partially formed ; 3d, from malformation or mal- 
position of parts of the heart or of vessels in immediate relation with the 
heart. 

The causes of malformations of the heart and of the vessels related to 
it are obscure, but the arrest of growth or abnormal development has been 
attributed to foetal inflammation of the parts involved. Occasionally the 
malformation appears to be due to some vice or taint in the system of one or 
both parents. Causes which promote the physical well-being, as pure air and 
outdoor exercise, plain and nutritious diet, freedom from depressing cares 
and anxieties in parents, diminish the liability to malformation and imperfect 
development of the foetal organs. 

Malformations of the heart derive their seriousness and importance from 
the fact that the heart is the central organ of circulation, so that when from 
malformation it is inadequate to perform fully its function, not only is the 
nutrition seriously interfered with, but the flow of blood through the lungs 
is insufficient. The blood is not properly oxygenated, and it is overcharged 
with carbonic acid, which imparts to it the deeply venous or livid color 
known as cyanosis. 

Cyanosis. 

As stated above, the cause of cyanosis when occurring in infants is at 
the centre of circulation, and is a malformation of the heart with very few 
exceptions. 

The blue disease, being so manifest, attracted attention at an early age. 
It appears from the remarks of Boerhaave that the common people believed 
that the cyanotic were possessed by evil spirits. 1 It was evidently impos- 

1 Diseases of the Humors. 



90 



DISEASES OF THE NEWLY-BORN. 



sible to understand its cause and nature prior to the discovery of Harvey in 
the seventeenth century, and most of the exact or scientific knowledge pos- 
sessed by the profession in reference to the etiology and nature of cyanosis 
has been achieved since the present century commenced. Boerhaave and 
Vieussens had observed cases and propounded theories in reference to it, but 
the knowledge of physicians concerning it remained vague and indefinite. 
No better idea can be given of the prevailing ignorance in reference to cya- 
nosis, even after the present century commenced, than by quoting from a case 
related by Ribes in 1814. 1 The patient had some time previously received 
an injury of the finger. " Many physicians of Amsterdam," says he, " were 
at different times consulted on the subject of this affection, no one of whom 
understood its true cause, its essential character. One considered it as par- 
taking of the nature of epilepsy, and caused by the irritation in the nervous 
system which the wound in the finger had produced. Others attributed it to 
the presence of intestinal worms. Some physicians pronounced it an injury 
to the liver or spleen. Many held it to be a scorbutic affection. One only 
believed it to be the result of an unknown organic disease." In the present 
century numerous carefully observed cases of cyanosis published in the 
medical journals, and the writings of Seiler, Louis, Bouillaud, Farre, Chev- 
ers, Peacock, Marston, Stille, and others, have contributed to a better under- 
standing of the nature and anatomical characters of cyanosis. 

Whatever may be the explanation, male infants affected with cyanosis are 
in excess of females : 

180 cases collated by Aberle .... two-thirds males. 

44 " " " Gintrac .... 28 males, 16 females. 

41 " " " Stille 21 " 10 

134 " " " J. Lewis Smith . 78 " 56 " 

The deaths from cyanosis illustrate the same fact : 



In London, England, in two years 
In New York City, in five vears . 



lales. 


Females 


418 


273 


117 


90 



Cyanosis, though dependent on a malformation, does not always com- 
mence at birth, or at least does not exist in degree sufficient to produce the 
cyanotic hue till some time has elapsed after birth. 

In 138 of the cases of cyanosis which I have collected the time at which lividity 
was first observed is stated as follows : In 97 it was within the first week, and gen- 
erally within a few hours of birth. In the remaining 41 cases it commenced as 
follows : 



In 3 at 2 weeks. 
" 1 " 3 " 
" 2 " 1 month. 
" 7 from 1 to 2 months. 
u 5 u 2 « 4 

" 5 " 6 " 12 " 
"3 " 1 year to 2 years. 



In 6 from 2 years to 5 years. 
a x it 5 a u 10 u 

a q a 10 a a go » 

a x a 20 " « 40 " 

" 1 over 40 years. 

41, total. 



In these 41 cases, in which blueness did not occur till after the age of one week, if 
the patient were less than two years old when it commenced there was frequently 
no obvious exciting cause, but above this age, with three exceptions, such a cause is 
known to have been present. 

It is interesting to observe how trivial the exciting cause frequently is, 

1 Bull, de la Fac. de Med,, 1815. 



MALFOBMA TIONS. 9 1 

and equally interesting to note how long patients have enjoyed good health, 
not having the least lividity, although the anatomical vice to which the final 
development of cyanosis was due had existed from birth. 

Dr. Theophilus Thompson relates l the history of a lady, thirty-eight years old, 
who was well till an attack of Asiatic cholera, after which her health was perma- 
nently impaired. Two years before her death she passed through a course of fever, 
and from this time was cyanotic. In the Philadelphia Medical Examiner, June, 
1850, Dr. Waters relates a case in which cyanosis began at the age of six years in 
an attack of measles. In a case published by Mr. Napper in the London Medical 
Gazette. 1841. the child fell at the age of six months, and from this time had cya- 
nosis. A female whose history is given by Prof. Tommasini of Bologna, and quoted 
by Bouillaud, became cyanotic at the age of twenty -five in consequence of difficult 
parturition. In the London Lancet, 1842, Mr. Stedman relates a case in which 
cyanosis began at the age of ten weeks in an attack of convulsions. In the Amer- 
ican Journal of Medical Sciences, in 1847, Dr. John P. Harrison published the his- 
tory of a baker, twenty years old, in whom cyanosis began five years previously 
after great effort in carrying wood. Louis and Bouillaud quote from M. Caillot the 
case of a child who became cyanotic at the age of two months in an attack of 
whooping cough. Louis also narrates a case in which whooping cough had the 
same effect at the age of twelve years. Ribes treated a child in whom the blue 
disease began at the age of three years from a severe contusion of the fingers. In 
a case by Marx it commenced at the age of ten months from a blow on the back 
inflicted by the mother. In the Medical Times and Gazette, for 1855, Mr. Speer 
gives the history of a female who at the age of thirteen years was put in a place 
requiring considerable exertion, and from this time was cyanotic. A patient whose 
case was related by Cherrier fell into a deep ditch in the winter season, and imme- 
diately after had a low fever, from which the blue disease commenced. In a case 
published by Tacconus the exciting cause was believed to be fright in consequence 
of a fall from a great height, and in another, related by Bouillaud, it was a blow 
received on the epigastrium after the patient had passed the age of fifty years. 

It will be seen that the exciting cause of cyanosis is usually such as pro- 
duces a profound impression on the system and affects the action of the heart. 
Precisely in what way it operates to develop the disease has not been satis- 
factorily explained. 

Mr. Mayo conjectures that in the case related by him there was previously some 
compensation which ceased or became inadequate in consequence of some change 
produced in the economy. Although cyanosis may not appear for months or even 
years, there is rarely improvement when it is once established. Appearances of 
amendment are deceptive. The disease when not stationary is progressive, and this 
explains the fact that few survive the middle period of life. 

Symptoms. — The symptoms in cyanosis vary in intensity in different 
patients, and in the same patient at different times, being milder if he be 
quiet and the mind calm, more severe if active or if the mind be agitated. 
In mild cases, in a state of rest, they nearly or quite disappear, so that a 
stranger would not suspect that there was any serious ailment. They are 
aggravated by any cause which accelerates the action of the heart. In some 
patients cyanosis is increased by the most trivial disturbing influences, among 
which may be mentioned nursing, dentition, crying, coughing, and slight 
emotions of joy, sorrow, or anger. In more than one case it has boon per- 
ceptibly increased by the stimulus of digestion, the color being deeper after 
a full meal than before. The cyanotic hue varies in different individuals 
from duskiness to a deep purple, almost black, color. It is usually most 
marked in the visage, especially the palpebne, cheeks, nose, and lips, in the 
ears, fingers, and upon the mucous surfaces. It is sometimes, without any 
assignable cause, confined to a portion of the body. 

In a case related by Mr. Steel in the London Lancet, 1838, the upper part of the 
1 Medieo-Chir. Tram., vol. xxv. 



92 DISEASES OF THE NEWLY-BORN. 

body was livid and oedematous, and the lower part pallid and shrunken, and yet the 
malformation was of the kind which is commonly present in cyanosis. In the 
London Medical Times. March 8, 1845, copied from the Gazette m6dicale, is the his- 
tory of a child, six years old, in whom the color was deeper on the right than left 
side. There had been, however, hemiplegia of this side in infancy, but this had 
entirely passed off. On the other hand, in a case of rare malformation communi- 
cated by Cooper to Farre, in which the upper part of the system was supplied 
chiefly by arterial and the lower by venous blood, the discoloration was general. 
In exceptional instances livid maculae, like those of purpura, have been observed 
upon the skin. 

Those affected with cyanosis have generally at birth been well formed 
and of the usual size, and in most cases for a considerable period after birth 
the appetite is good, bowels regular, and the system well nourished. But 
when cyanosis becomes so severe, as it does sooner or later, that its symptoms 
are rarely absent, digestion is imperfectly performed and the body becomes 
either emaciated or stunted and puny. It may be stated, as a rule, that 
nutrition is in inverse proportion to the gravity of cyanosis. 

In 33 out of 41 cases in which the condition of the system as regards nutrition 
was recorded either a short time previously to death or at the autopsy, the body was 
either considerably emaciated or else diminutive, and those who were well nourished 
were usually such as had died early or of some intercurrent disease. 

In this connection may be mentioned two abnormalities which have been 
observed in the cyanotic. The chest is often flattened laterally, with a pro- 
jecting sternum, so as to present an appearance generally described in the 
records as " pigeon-chested." Sometimes the most prominent part is directly 
over the heart, and in one or two cases the sternum was observed to be 
deflected toward the left. In the majority of the records, however, no men- 
tion is made of the external appearance of the chest. 

The other abnormality is frequently observed in chronic diseases of the 
heart and lungs, in which there is sluggish circulation and consequent altered 
nutrition in the fingers and toes. In 28 of the cases collated by myself it is 
stated that the tips of the fingers or toes, or both, were bulbous. This 
hypertrophy, if slight, is likely to be overlooked, and that it was observed 
and recorded in so many cases renders it probable that it was present in a 
much larger number. In one case the anatomical character of this enlarge- 
ment was minutely examined, and was found to consist chiefly of hypertro- 
phied connective tissue. 

The nails are often incurvated over the deformity. At a meeting of the London 
Pathological Society, in 1859, Mr. Ogle narrated the history of a laborer fifty years 
old who had swelling, numbness, and lividity of the left arm from pressure of an 
aneurism, and the fingers on this side were clubbed. 

An interesting feature in cyanosis is the low grade of animal heat. The tem- 
perature of the body is in all cases below that of health. This is especially notice- 
able in the extremities. There has not been a sufficient number of accurate ther- 
mometric observations to determine whether the internal heat is usually reduced. 
The following only have been recorded : Mr. Fletcher relates the history of a young 
man in the Medico-Chir. Trans., vol. xxv., in whom the thermometer placed in the 
mouth did not stand above 80° Fahr. Hodgson reports the case of a man, twenty- 
five years old, in whom the thermometer placed under the tongue rose to 100°. 
Perhaps a more thorough examination might have disclosed an intercurrent malady 
to cause fever. In an examination recorded by Nasse the instrument placed in the 
mouth fell little if at all below the healthy standard ; applied to external parts, it 
stood at about 21° Reau. == 79.2° Fahr. 

The lack of heat is a source of great discomfort to a cyanotic patient. 
In mild weather he requires a fire to keep him warm or an amount of cloth- 
ing which to others would be uncomfortable, and in cold weather slight 



MALFOBMA TIONS. 93 

exposure strikes him with a chill. Nor can he increase his heat by active 
exercise, since his infirmity disqualifies him for this. Although the tempera- 
ture of the surface is so low, the occurrence of perspiration, sometimes pro- 
fuse, is mentioned in several of the records. 

In severe cases of cyanosis the generative system is imperfectly devel- 
oped. In the female menstruation is scanty or delayed, and in the male signs 
of puberty are feebly manifest. If the disease be so mild that the symptoms 
are absent when the patient is in a state of repose, these organs attain nearly 
or quite their normal development. The catamenia have appeared as early 
as the age of sixteen years, and a cyanotic patient treated by Cherrier had 
two children, but both died of scrofulous affections. 

The action of the heart is necessarily much involved. In mild forms 
of the disease, if the patient be quiet, this organ may beat with considerable 
slowness and regularity, but in all cases exercise or excitement which in 
a state of health would scarcely have any appreciable effect on the pulse 
embarrasses its movements and produces palpitation. In severe cases pal- 
pitation is rarely absent, and the pulse is frequent, feeble, and often inter- 
mittent. In a large proportion of patients bruits are produced by the irreg- 
ular circulation through the heart. 

The respiration corresponds with the action of the heart. It is accele- 
rated in proportion to the frequency of the pulse. The suffering in this 
disease is largely due to paroxysms of palpitation and dyspnoea. These 
occur sometimes without any apparent exciting cause and when the patient 
is quiet, but they are commonly induced by those causes which we have 
already mentioned as aggravating the symptoms of cyanosis. They come 
on suddenly, and are attended by increase of lividity, distention of the jug- 
ulars, and sometimes of the cutaneous veins, and by a sensation of present 
suffocation. They last only a few minutes, and are succeeded by great 
depression of the vital powers. In infants, on account of greater nervous 
irritability and feeble power of endurance, these paroxysms often end in con- 
vulsions which occasionally are fatal. A cough is sometimes present, but is 
usually slight. 

Pain is not a common symptom. Some of the patients complain occasion- 
ally of headache, with or without vertigo, and occasionally also of pain in 
the chest, but it is uncertain to what extent or whether these symptoms are 
dependent on the cyanotic disease. The secretions do not appear to be affect- 
ed, so far as has been ascertained. The same may be said of the intellectual 
and moral faculties. In a case related by Dr. Cheevers the child was even 
said to be precocious. 1 The mind is capable of steady application and acqui- 
sition, as in health, provided that the emotions are not unduly excited. 

The cyanotic are liable to various forms of hemorrhage, but the records 
show that this liability is greater in youth and adult life than in infancy. In 
2 cases blood was vomited, in 1 passed by stool, in 1 it escaped from the gums. 
in 2 from the mouth, in 8 from the nostrils, and in 16 it was expectorated. 
Pulmonary phthisis was, however, usually present in these last cases. In 
the Western Journal of Medicine for 1829 an interesting case is related by 
Dr. William M. Voris of a girl nine years old in whom hemorrhage occurred 
under the scalp, producing great tumefaction and nearly closing the eye- 
lids. An incision was made, from which a pint and a half of dark blood 
escaped, and it was estimated that more than half a gallon was lost during 
the ensuing two weeks, at the expiration of which time the incision closed. 
The patient recovered from the hemorrhage, but not from the cyanosis. 

Toward the close of life more or less anasarca occasionally occurs, espe- 
cially around the ankles, sometimes in the eyelids and face, and rarely to a 

1 Lond. Med. Gaz., vol. xxxviii. 



94 



DISEASES OF THE NEWLY-BORN. 



certain extent over the whole body. In certain patients it coexists with 
effusion in the serous cavities. 

It is evident that one who is affected with the severer form of cyanosis is 
disqualified for the duties of active life. The sports of childhood and the 
useful labors of mature years require an exertion for which he is physically 
unfit. He has not the ability even to engage in animated conversations, for 
he is overcome by emotions, whether of joy or sorrow. He lives almost 
an idle spectator of the world around him, prevented by his infirmity from 
engaging in its pursuits. 

Intercurrent diseases, especially those of childhood, are badly tolerated, 
but whooping cough is the one which these patients are especially ill-fitted to 
endure. Still, they sometimes pass safely not only through whooping cough, 
but through some of the most dangerous febrile diseases. It is a question 
of interest, but about which little is known with certainty, whether these 
intercurrent maladies are influenced by the cyanotic or venous condition of 
the blood. The symptoms of these maladies are no doubt more alarming, 
mainly on account of the embarrassed action of the heart, and not on account 
of the state of the blood ; still, it is reasonable to suppose that malignant 
and asthenic diseases are rendered worse by the lack of oxygen and excess 
of carbonic acid in the circulating fluid. 

Probably cyanosis does not furnish immunity from any other disease, 
although this statement has been made by a high authority. 

Rokitansky says : " All forms of cyanosis, or rather all the diseases of the heart, 
great vessels, and lungs adapted to produce cyanosis in a greater or less degree, 
cannot coexist with tuberculosis. Cyanosis affords a complete protection against it, 
and in this circumstance may be found an explanation of the immunity from tuber- 
culosis which many conditions of the system, apparently very different in their 
character, afford. ,; 1 This opinion of the distinguished pathologist, notwithstanding 
his ample opportunities for observation and known accuracy as an observer, is not 
substantiated by statistics. So far from its being true, the low degree of vitality in 
cyanosis appears to favor the occurrence of tubercles. I have records of 26 cases 
of cyanosis in which tuberculosis was also present, in several of which the lungs 
contained cavities. This is about 13 per cent, of the whole number in my collection 
— a large proportion, since so many die in early infancy, at which period the tuber- 
cular disease seldom occurs. Cyanosis appears also to favor the development of 
cerebral diseases, especially congestion and coma, as will be seen presently. 

Prognosis. — This is unfavorable. Most cyanotic individuals die young. 
The age which they attain has been made the subject of statistical inquiry 
by Aberle. 

He states that in an aggregate of 159 cases, 57, or 35 per cent., died before the 
end of the first year ; 108, or more than two-thirds, died before the age of eleven 
years ; 30 between the ages of eleven and twenty-five years ; and of the remaining 
21, only 5 lived more than forty -five years. 

The age at which death occurred is given in 186 of the cases collected by myself, 
as follows : 



In 17 under the age of 1 week. 
" 10 from 1 week to 1 month. 



12 < 


' 1 month to 3 months 


11 l 


' 3 months to 6 " 


17 ' 


' 6 " to 12 " 


12 < 


' 1 year to 2 years. 


21 ' 


1 2 years to 5 " 



In 21 from 5 years to 10 vears. 
" 41 " 10 " " 20 " " 
" 20 " 20 " " 40 " 
" 4 over 40 " 



186 total. 



67, then, or more than one-third, died before the close of the first year ; 121, or 
more than three-fifths, before the age of ten years ; only 24 survived the age of 

1 Handb. der Path. Anat, Bd. ii. 



MA LFOBMA TIONS. 9 5 

twenty years, and 4 the age of forty years. Of course, the duration of life depends 
on the nature and extent of the malformations. Some of these are such as render 
a speedy death inevitable. 

Mode of Death. — The mode of death is reported in 95 cases, as fol- 
lows : 

19 died in a paroxysm of dyspnoea. 
10 " suddenly (the exact manner not stated). 
14 " in convulsions (infants). 
2 " of apoplexy. 

from hemorrhage. 



6 " of phthisis (though, as we have seen, 20 others had this disease). 

2 " of exhaustion, without hemorrhage. 

10 " of coma. 

2 " of abscesses in the brain. 

One died of each of the following diseases : cerebral irritation, congestion of 
brain, effusion in the cranial cavity, acute hydrocephalus, paralysis from acute 
softening of the brain, dysentery, inflammation of heart, syncope, mucus in the air- 
passages, thoracic inflammation, choleraic diarrhoea, pneumonitis, bronchitis, scarlet 
fever, croup ; 1 died in trying to walk, 1 after a spasmodic cough in pertussis, 1 after 
a long agony of ten or eleven hours ; 1 is reported to have died gradually, and 3 
quietly. 

The 10 who are stated to have died suddenly probably died in paroxysms of 
palpitation and dyspnoea, which are easily excited and of common occurrence in 
cyanosis. If so, this was the mode of death in 29 cases. Infants with few excep- 
tions, so far as appears from the records, died in convulsions. 19 died of cerebral 
affections, exclusive of convulsions, and in 13 of these the cause of death was con- 
gestion, apoplexy, or coma. The hemorrhage of which 7 died was probably, in 
most instances, dependent on phthisis, and 6 are said to have died directly of 
phthisis. We may, then, regard paroxysms of palpitation and dyspnoea, convul- 
sions, congestive affections of the brain, and phthisis as common modes or causes of 
death in cyanosis. 

The malformations of the heart and great vessels which give rise to 
cyanosis are quite numerous. The following table exhibits their character 
and relative frequency : 

Cases. 

1. Pulmonary artery absent, rudimentary, impervious, or partially obstructed 97 

2. Eight auriculo- ventricular orifice impervious or contracted 5 

3. Orifice of the pulmonary artery and the right auriculo-ventricular aperture 

impervious or contracted 6 

4. Eight ventricle divided into two cavities by a supernumerary septum ... 11 

5. One auricle and one ventricle 12 

6. Two auricles and one ventricle 4 

7. A single auriculo-ventricular opening ; interauricular and interventricular 

septa incomplete 1 

8. Mitral orifice closed or contracted 3 

9. Aorta absent, rudimentary, impervious, or partially obstructed 3 

10. Aortic and the left auriculo-ventricular orifice impervious or contracted . 1 

11. Aorta and pulmonary artery transposed 14 

12. The cavse entering the left auricle 1 

13. Pulmonary veins opening into the right auricle or into the cava 3 or azygos 

veins 2 

14. Aorta impervious or contracted above its point of union with the ductus 

arteriosus ; pulmonary artery wholly or in part supplying blood to the 
descending aorta through the ductus arteriosus 2 



Total 16 



From the above table it appears that in more than one-half oi' the eases 
of cyanosis the congenital vice which gives rise to it is located in the pul- 



96 DISEASES OF THE NEWLY-BORN. 

monary artery. It is located also, in general, in that part of the artery which 
is nearest the heart. Its character is different in different cases. Sometimes 
there is an arrested development of this vessel, and in its place we find simply 
a ligamentous cord extending from the- heart as far as the ductus arteriosus, 
while beyond this point the artery and its branches are pervious ; rarely the 
entire artery is ligamentous, and of course impervious ; in other cases this 
vessel is open through its whole extent, but the part nearest the heart is so 
small as to be properly considered rudimentary ; in others still there is adhe- 
sion of the valves to each other as the chief congenital defect ; and finally, 
in rare instances the obstruction in the pulmonary artery is due to an adven- 
titious membrane which stretches across the vessel like a diaphragm. These 
last malformations — namely, adhesion of the valves and the formation of an 
adventitious membrane — are doubtless due to inflammation occurring in the 
artery before birth, and some attribute the arrested development and lig- 
amentous state of the vessel to the same cause. 

In most cases of cyanosis due to obstructive malformations the inter- 
auricular and interventricular septa are more or less deficient. This deficiency 
obviously results from the obstruction, for the septa are formed in the heart 
after foetal circulation is established, and the blood, being prevented by the 
vicious formation from flowing in its proper channel, necessarily passes to 
the opposite side of the heart. More or less blood being forced from one 
auricle or one ventricle to the opposite cavity, it is evident that a permanent 
aperture must result in the septum. The aperture in the septum ventricu- 
lorum is ordinarily at its base ; in the septum auriculorum it corresponds 
with the foramen ovale. 

In most of the obstructive malformations one, and rarely two, abnormal 
cardiac murmurs have been observed. The single murmur accompanies the 
ventricular systole. As it has been observed in cases of complete as well as 
incomplete obstruction, it seems to be due mainly to the flow of blood through 
a narrow or constricted pulmonary artery or the apertures in the septa. 

Modes of Compensation. — In most cases of cyanosis the congenital 
defect is partially obviated by modes of compensation. In the most fre- 
quent malformation, that in which there is obstruction in the pulmonary 
artery and a considerable part if not all the blood flows directly from the 
right to the left side of the heart, the ductus arteriosus not only remains 
open, but is greatly enlarged, and through it a current of blood enters the 
pulmonary artery from the aorta, and, passing to the lungs, is oxygenated. 
The bronchial arteries have also been found greatly enlarged, and it is believed 
that, though they are the nutrient arteries of the lungs, the blood which they 
convey to these organs is decarbonized in its circuit through them. 

In a case published by Mr. Le Gros Clark in the Medico- Chir. Trans., vol. xxx., 
the bronchial arteries were not only enlarged, but a " branch from the internal 
mammary artery, which accompanied the phrenic nerve, was nearly equal in size 
to the parent trunk, and expended itself principally in the adjacent adherent lung. 
Branches of the intercostal arteries have also been found enlarged, and entering 
the lungs or connecting with vessels which enter the lungs.' ■ 

By such modes of compensation cyanosis is rendered milder and life is 
prolonged. To these we must attribute the fact that some have very con- 
siderable malformation and yet do not become cyanotic. 

Morbid Anatomy. — This, as regards the circulatory system, has been 
sufficiently dwelt upon. No chemical analysis, so far as I am aware, has yet 
been made of cyanotic blood. We know that it is dark, its coagulability 
feeble — that it contains an excess of carbonic acid and is deficient in oxygen. 
From the nature of cyanosis it would be inferred that in many cases there is 
a degree of passive congestion in the cavities of the heart, and consequently 



MALFORMATIONS. 97 

in the capillaries of the systemic system, giving rise to more or less serous 
effusion. 

Statistics show that this is so. The quantity of pericardial fluid is in some 
patients increased. I have records relating to this fluid in 51 cases. Usually it 
was pure serum. In IT the quantity was half an ounce or less, if we include in 
the number those in which the amount is expressed in such terms as "due quan- 
tity.*' "usual amount," and "small amount." In 24 cases the pericardial fluid 
(serum) exceeded half an ounce, usually estimated at from 1 to 6 ounces, but in 
2 it exceeded the latter quantity. In 1 of the 24 this fluid was stained with 
blood. In 2 patients the records state that there was a small quantity" of pure 
blood in the pericardium, and in 1 the two pericardial surfaces were agglutinated 
by inflammation. 

In some of the autopsies serum was found in the pleural cavities, usually 
in connection with pericardial effusion, and in at least one instance this fluid 
was tinged with blood. Old adhesions between the costal and pulmonary 
pleura were observed in a few cases. The condition of the lungs was 
recorded with more or less minuteness in 110 cases. Mention has already 
been made of the large number affected with tubercular disease, which was 
either confined to the lungs or was chiefly exhibited in these organs. In 35 
patients the records state that the lungs were of small size, either by com- 
pression or sometimes, apparently, from the continuance of the foetal state 
over a greater or less portion of the organ. The compression was produced 
either by the distended pericardium or by effusion in the pleural cavities. In 
35 cases the lungs presented a dark color. This hue in some specimens 
accompanied the unexpanded or fcetal state of the organ, but in others there 
was the normal inflation, and the dark color was due to engorgement or con- 
gestion. In other cases the lungs are stated to have been natural except the 
color. In 9 emphysema was present in a part of the lungs, in 2 pneumo- 
nitis ; in 2 the color of the lungs was pale, in 1 a bright crimson ; in 1 the 
lungs were larger than natural, in 1 the right lung was absent, and in 17 
these organs were recorded healthy. 

I have records of the state of the liver in 26 cases, in 16 of which it was 
enlarged, and in 4 of these it was congested. Congestion of the liver was 
present in 8 other cases in which no mention is made of its volume. The 
substance of the liver had a natural appearance in 9 cases, but in some of 
these this organ was enlarged. From these statistics it is probable that the 
liver is commonly enlarged in cyanosis, and not infrequently congested. In 
a few cases the condition of the other abdominal viscera is mentioned — in 
some as heathly, in others as congested. Fifteen examinations of the brain 
were made, in 7 of which congestion is recorded, and in 3 abscesses in the 
cerebral substance, in 1 of which cases the lateral ventricle was also filled with 
pus ; in 2 softening of a portion of the brain had occurred, in 3 the brain was 
firm or compact, in 3 the quantity of fluid in the cranial cavity exceeded the 
normal amount, and in 1 it was less than normal. 

Theories relating to the Etiology of Cyanosis. — Although in nearly all 
cyanotic patients there are direct communications between the two sides o( the 
heart, it is shown by many observations that these communications or apertures 
are not sufficient in themselves to produce cyanosis. This opinion was expressed 
half a century ago by Louis, who published an excellent monograph on the subject 
of these communications, basing his remarks on an analysis of twenty eases. Since 
the publication of this paper the belief has been pretty general in the profession — 
and observations continue to substantiate it — that although the apertures may be 
of considerable size, if the two sides of the heart, with their orifices and vessels, are 
in their normal state, so that they act symmetrically and without obstruction, the 
blood is sufficiently oxygenated and decarbonized, and cyanosis does not occur. In 
proof of the correctness of this opinion many cases might be cited of a pervious 
7 



98 DISEASES OF THE NEWLY-BORN. 

and some of a largely dilated foramen ovale without the cyanotic hue — cases which 
have been published in the journals since the appearance of Louis's monograph. 
Still, in cases of obstructive malformation, unless the obstruction be complete, 
cyanosis is more likely to occur in consequence of these apeitures, for were they 
absent a larger amount of blood would be propelled through the narrow orifice of 
the pulmonary artery, and a larger amount consequently be oxygenated. 

Allusion has already been made to the two theories which prevail in the pro- 
fession : the one attributing the non-oxygenation of the blood and its highly venous 
character, so as to cause the cyanotic hue. to the intermingling of venous and arte- 
rial blood : the other to obstruction at the centre of circulation, and consequent 
venous congestion. There are serious objections to the acceptance of either theory 
as an explanation of all cases. That admixture of the two kinds of blood is not 
essential to the production of cyanosis is apparent from the following facts : In one 
case in the Fourth Malformation there was no communication between the two sides 
of the heart, and the ductus arteriosus was closed, so that admixture was impossible. 
Again, in the Eleventh Malformation, or that in which the aorta and pulmonary 
artery are transposed, the blue disease evidently does not depend on the admixture 
of the two currents. On the other hand, in this curious state of the heart the more 
the admixture the less the cyanosis, since the only way in which the systemic 
current of blood can be oxygenated is by passing to the opposite side of the heart. 
An argument against this doctrine may also be found in the fact that the modes 
of compensation are not such as in any way to diminish or obviate the admixture. 
It is admitted that in the more frequent malformations cyanosis is increased by the 
apertures which allow the intermingling of the venous and arterial currents, but 
it is more reasonable to consider the intermingling and the cyanosis as the direct 
results of the malformation, neither having the precedence of the other, than to 
consider that they are related to each other as cause and effect or as proximate and 
remote results. Viewed in this light, the admixture must be considered simply a 
concomitant of the cyanosis. 

The second theory, that of venous congestion, has numbered among its advocates 
many who have given special attention to the subject, as Morgagni, Louis, and 
Stille, but it seems to have even less claim for acceptance than the theory of admix- 
ture. It has been seen that in nearly all cases of cyanosis the two sides of the heart 
communicate freely, so that if the current of blood meets with an obstruction, as it 
commonly does, it readily escapes to the opposite side, where the artery is large and 
gives it free passage. In this way congestion, if not prevented, is greatly dimin- 
ished. Again, it will be seen that, although certain of the viscera are frequently 
found at the autopsy more or less congested, congestion is not uniformly present 
in the organs, as it would probably be were it the proximate cause in all cases of 
cyanosis. 

Moreover, in some patients the malformation is not obstructive. The cavities 
and their orifices are of the normal size, and cyanosis is due entirely to malposition 
of the vessels. It cannot be said that in these cases there is venous congestion from 
arrest at the centre of circulation. If there be any congestion, it must be due to 
the fact that venous blood does not circulate as readily as the arterial in the capil- 
laries. It is true that in the paroxysms of dyspnoea there is sometimes more or 
less congestion — the distention of the jugulars shows this — but it subsides with the 
paroxysms, and it probably is no more than usually occurs when respiration is 
greatly embarrassed. 

In fine, attempts to express the immediate pathological state producing cyanosis 
in the terms of a general law have failed. However plausible the above theories 
may appear in regard to certain cases, there are others to which they are manifestly 
inapplicable. Those who advocate these theories seem to lose sight of the obvious 
fact that the chief want of the economy in cyanosis is decarbonization of the blood, 
and it is hardly supposable that there can be any correct theory of its causation 
which is not founded on this fact. With this physiological state in view, it does 
not seem difficult to express a theory in comprehensive terms which is applicable to 
all cases, such as the following : Cyanosis is due to malformations of the heart and 
the great vessels in immediate relation with the heart, which prevent the proper 
flow of bipod to and from the lungs, so that the oxygenation and decarbonization 
of this fluid are inadequate. So comprehensive a statement includes not only cases 
of malformation and malposition of the heart and its vessels, but also those few 
cases in which the lungs are in fault. In most patients, as we have seen, the cur- 



MALFORMATIONS. 99 

rent of blood toward the lungs is obstructed, and the current of blood from the 
lungs is obstructed in those comparatively rare cases in which the malformation is 
on the left side. 

Treatment. — From the nature of cyanosis it is evident that the treat- 
ment should be more hygienic than medicinal. The patient should be warm- 
ly clad and kept in a warm room, and all agencies calculated to embarrass or 
disturb the functions of the body or excite the emotions, and thereby accel- 
erate the heart's action, should be studiously avoided. The diet should be 
nutritious, but simple and easily digested. 

Those who have attributed cyanosis wholly to apertures in the inter- 
auricular and interventricular septa, and the consequent flow of blood from the 
right to the left side of the heart, have considered it an important part of 
the treatment to keep the patient reclining on the right side, so as to dimin- 
ish this flow by the effect of gravitation. The reader, however, must be 
convinced from the nature of the malformations that little benefit can accrue 
from following such advice. Still, patients are sometimes less cyanotic and 
more comfortable in one position than in another. 

In a case reported by Mr. Howslip 1 " the only easy and indeed comfortable 
position in which the child could remain was that usual in nursing. "When erect 
the dusky color of the face and neck became a dark-blue." In a case related by 
Mr. Spackman 2 the patient was easiest on the hands and knees. Louis reports a 
case 3 in which the selected position was with the head elevated ; Wm. Hunter a 
case * in which the patient avoided paroxysms by lying on the left side. Struthers 
and King each report a case in which the patient seemed most comfortable while 
lying on the right side; 5 but, on the other hand, Professor White of Buffalo 6 and 
Dr. James Carson 7 report cases in which position on the right side failed to pro- 
duce any alleviation of symptoms. Other similar observations might be cited, but 
enough have been mentioned to show that no one position should be recommended 
for cyanotic patients. Some obtain most relief by lying on the back, others on the 
right side, others on the left ; some when on the hands and knees, some when reclin- 
ing on either side indifferently, while, finally, others suffer least when erect. 

There was a time when the paroxysms were treated by venesection, but 
depletion has long since been abandoned. Physicians now rely on stimu- 
lants, antispasmodics, friction to the chest, and mustard pediluvia to relieve 
the urgent symptoms, although this treatment is but partially successful. 
It is probable that of all internal remedies digitalis is the most useful, from 
the fact that it is an efficient heart-tonic and more than any other medicine 
gives strength and equality to the heart-beats. In the cities where oxygen 
gas can be procured for daily inhalation the urgent symptoms may in some 
instances be partially relieved by the use of this agent. 

Caput Succedaneum. 

During the birth of the child extravasation of blood frequently occurs 
in the part of the scalp which presents. It results from the passive conges- 
tion which occurs in presenting parts, and is greatest in amount when the 
labor has been protracted and the labor-pains unusually severe. Caput suc- 
cedaneum is the term employed to designate the swelling thus produced. Its 
seat is in the loose connective tissue between the scalp and pericranium, and 
it consists partly of extravasated blood, but largely of serum which has 
transuded from the congested vessels before that degree of congestion 
required to affect the transudation of corpuscles or rupture of capillaries 

1 Edin. Med. Journ., 1813. 2 Lond. Med. Gas., 1833. 

3 Be la Commun. des Cav., etc. * Med. Obs. and Enq., vol. vi. 

5 Monthly Journ. of Med. Sci. 6 Buf. Med. Journ., 1855. 

7 Amer. Journ. of 3Ied. Soi., 1857. 



100 DISEASES OF THE NEWLY-BORN. 

was reached. I have repeatedly had an opportunity to examine this tumor 
in stillborn infants, and have found when it was slight that it consisted almost 
entirely of serum, but ordinarily when dissected it presented the appearance 
of a bruise, with a large proportion of serum, the blood and serum infiltrat- 
ing the scalp to a greater or less distance beyond the appreciable limits of 
the tumor. Caput succedaneum requires no treatment. As it lies in the 
loose connective tissue of the scalp, its liquid permeates the open interspaces 
in this tissue in every direction, and is rapidly absorbed, with the disappear- 
ance of the tumor. Its subsidence is usually complete within twenty-four 
hours. 

Cephalhematoma. 

Occasionally during birth blood is extravasated under the pericranium, 
detaching it from the bone. This commonly occurs in connection with caput 
succedaneum, and is observed when the latter declines. Its common seat is 
upon the occipital or parietal bone, near the posterior fontanel, most fre- 
quently upon the parietal, where the pressure during labor is greatest. Prof. 
Henoch states that the tumor does not obtain its maximum size immediately, 
but gradually increases by the continued escape of blood until the third day. 
The tumor may extend over the entire surface of the bone, but it does not 
pass beyond the suture. Cases of bilateral cephalhematoma have been 
reported, but they are rare. The tumor is fluctuating, and the skin covering 
it has the normal appearance or a bluish tinge, or it may exhibit infiltrations 
of blood like a bruise. Since the pericranium elevated by the blood does not 
lose its vitality, it begins to secrete from its under surface preparatory to the 
formation of bone. In a few days we are able to detect by pressure with 
the fingers a hard projecting rim at the border of the tumor, the result of 
the secretion and bony formation at the point where the pericranium is 
in part detached and in part adherent. If the tumor is tense, we are unable 
to detect the bone underneath by pressure, and the hard elevated rim resem- 
bles the edge of an opening in the skull. The cephalhematoma when not 
disturbed apparently causes little or no suffering, but the infant evinces pain 
if pressure be made upon it. Usually in the second week absorption is so far 
advanced that the tumor is less tense, and on pressure the bone can be felt 
underneath it. Complete absorption of the blood which has remained liquid 
usually occurs in four or five weeks. 

Not infrequently, when absorption occurs slowly, a thin layer of bony 
substance forms in a few weeks on the under surface of the pericranium. 
This causes a creaking sound when pressure is made upon it. In a case in my 
practice the child died about two months after birth, and the blood constitu- 
ting the tumor, which had been in great part absorbed, was completely encased 
by the old bone below and the new bony formation above. As the blood 
becomes absorbed the pericranium, having perhaps a bony formation on its 
under surface, gradually sinks ; the cavity at length becomes obliterated ; 
and there only remains some thickening of that part of the cranium which 
corresponds with the site of the tumor. 

A cephalhematoma might be mistaken by the inexperienced for a con- 
genital meningocele, since the ridge described above which forms along its 
border resembles so closely the edge of an opening, and both tumors are 
fluctuating ; but a meningocele rarely occurs upon the part of the head 
occupied by the cephalhematoma ; and if there be any doubt in the diagnosis 
at first, it will be dispelled in a few days by the changes which it undergoes. 

The treatment should be expectant, except that a soft covering of cot- 
ton should be placed over the tumor to prevent injury. Neither incision nor 
aspiration is advisable. 



HEMATOMA OF THE STERNO-CLEIDO-MASTOID MUSCLE. 101 

CHAPTER II. 

LOCAL DISEASES. 

Hematoma of the Sterno-cleido-mastoid Muscle. 

We sometimes observe in infants, usually between the ages of one and 
six weeks, a hard tumor upon the antero-lateral aspect of the neck cor- 
responding to the site of the sterno-cleido-mastoid muscle, and evidently 
developed in this muscle, It is round or more frequently elongated, varying 
from the size and shape of a pigeon's egg to that of the little finger, occupy- 
ing the anterior border of the muscle. Sometimes the tumor, hard like 
cartilage to the touch, extends over the anterior half of the muscle ; and it 
is stated to occur more frequently in the right than in the left muscle. Prof. 
Henoch observed it on the right side in 16 cases and on the left side in 5 
cases. 

The following was a typical case: On July 19, 1887, I attended Mrs. S-i , a 

primipara, in her confinement. Her labor, which was tedious, was terminated by 
the forceps, without any appreciable injury of mother or child. About one month 
after her confinement the mother stated that she had observed during the last two 
weeks an unusual swelling passing obliquely along the side of the neck of the child. 
I found the anterior portion of the sterno-cleido-mastoid muscle thickened and 
hard from a point about two lines above its lower attachment nearly its entire 
length. The swelling was of the size and shape of the little finger of a child of 
twelve years. It was tender to the touch, never had been red, and the infant's con- 
dition was normal in every other respect. At the age of nine weeks the tumor was 
still appreciable, but had nearly disappeared. Sometimes the tumor is not continu- 
ous, but the muscle is thickened and hardened in two or three different places. 
Occasionally the child's head is turned to one side, either from the pain in holding 
it erect or because the function of the muscle is impaired. 

The etiology and nature of this tumor are apparent from the history. 
In a majority of the cases the birth of the infants affected with this ailment 
is tedious, and in many the presentation at birth is abnormal. This tumor 
is especially liable to occur after breech presentations, which necessitate trac- 
tion upon the neck. In head presentations, when there is delay in liberating 
the shoulders and traction is made on the head, and especially if forcible 
rotation is made, the more superficial and exposed fibres in the sterno-cleido- 
mastoid muscle are liable to rupture ; and when this occurs a local myositis 
results, causing the tenderness, infiltration, and swelling. Certain writers 
state that more or less extravasation of blood takes place at the time of the 
accident and before the inflammation supervenes, and hence the term " hema- 
toma " which has been employed to designate the disease. 

The prognosis is good. Suppuration does not occur unless under very 
unusual circumstances, and, though probably more or less cicatricial tissue 
results at the seat of injury, the function of the muscle is not appreciably 
impaired when the inflammation and swelling abate. No perceptible contrac- 
tion or deformity results. 

But little treatment is required ; indeed, patients do well without treat- 
ment. But it is best for the infant that it maintain so far as possible a hori- 
zontal position, with the head resting on a pillow and with the avoidance of 
rotation so long as the disease is in its active state and the tumor is tender 
to the touch. Probably cool lotions recommended by some are as likely to 
do harm as benefit by giving cold to the child and producing nasal or other 



102 DISEASES OF THE NEWLY-BORN. 

catarrhs. Inunction with an ointment of iodide of potassium has been recom- 
mended for the purpose of promoting absorption, as the following : 

R. lodidi potass., 

Aquse, da. 1 part ; 
Adipis, 2 parts ; 

Lanolin, 6-8 parts. 

But without this treatment absorption is progressive and cure complete within 
a few weeks. 

Mastitis. 

In newly-born infants the secretion of a milk-like substance begins at about 
the fourth day in the mammary glands. It increases until the tenth day, when 
it gradually diminishes, and disappears at about the twentieth day. It is 
attended with some swelling of the glands during the period of their activity, 
and after the secretion ceases the enlargement gradually abates. A section 
of the gland in which this secretion has occurred, made near the surface, 
shows epithelium. At a greater depth the canals enlarge, divide, and end in 
cavities which are filled with a liquid having the appearance and character 
of colostrum. This glandular activity, it is said, may begin before birth, and 
continue six or eight weeks after birth, but the period of greatest enlarge- 
ment and most active secretion of the gland is usually between the fourth 
and tenth days after birth, as stated above. 

In exceptional instances the enlargement of the gland and its functional 
activity result more seriously. The gland becomes inflamed, and an abscess 
may occur as in the adult female. The nurse may produce this result by 
rubbing and pressing the gland, so that rude manipulation of it should be 
avoided. An abscess destroys the gland-structure, which is a serious result 
if the infant be a female. 

M. Bouchut, in his practical treatise on diseases of the newly -born (p. 719, 1867), 
relates a fatal case of mastitis in which the inflammation extended to the connective 
tissue, and ulceration so extensive occurred that the pectoral muscle was exposed, 
and death resulted from prostration. Jacobi has observed similar cases. 1 

Therefore in treating the enlarged and secreting gland of early infancy 
very gentle and unirritating measures should be employed, so that mastitis 
may, if possible, be prevented. The dress should be loose, so as to avoid 
pressure on the gland. If no inflammation, or inflammation in its commence- 
ment, be present, absorbent cotton or cotton soaked with sweet oil should be 
applied, and covered with oil silk. It is proper also to apply a mild lead wash 
to the enlarged mammary gland, especially if it be hot. If it be indolent, 
iodide of potassium in glycerin, one part of the former to ten of the latter, 
may be used. If the gland be hot, and especially if it be red, a soft emol- 
lient poultice should be applied, as of bread and milk or flaxseed and water. 
If, unfortunately, suppuration occur, an early incision should be made as far 
as possible from the nipple. In the subsequent treatment mild antiseptic 
washes, as boric acid or listerine and water, should be used. Corrosive sub- 
limate should not be employed, as young infants are readily poisoned by it, 
and, for the same reason, carbolic acid should not be used or be used in a very 
weak solution. Iodoform should also not be used, or used largely diluted by 
the addition of starch. 

Conjunctivitis. 

Different forms of conjunctival inflammation occur in the newly-born. In 
the mildest variety no appreciable swelling of the lids occurs, and only a little 
viscid secretion collects between the lids, which agglutinates them in sleep, 

1 Archives of Pediatrics, March, 1888. 



OPHTHALMIA NEONATORUM. 103 

and which the nurse readily removes by bathing them with tepid water or 
milk and water, and in a few days effects a cure. On the other hand, the 
purulent form of conjunctivitis, which is observed on the second or third day 
after birth, and which arises from the reception between the lids of the vagi- 
nal secretion of the mother, always involves great danger to the eye, speedily 
producing opacity or destruction of the cornea, unless promptly and properly 
treated. Between these two extremes conjunctivitis neonatorum occurs in 
different grades of severity. 

Mild or Catarrhal Conjunctivitis. — This, as the name indicates, is a simple 
catarrh, attended, as stated above, by a slight viscid secretion from the lids 
and by little or no swelling. The secretion collects in the angles of the lids 
and along their margin. This mild conjunctivitis requires very simple treat- 
ment. Warm water or milk and water should be gently applied by a large 
camel's-hair pencil, so as to wash away the secretion as soon as it forms, and 
sweet oil or vaseline should then be applied between the lids. With these 
simple measures this mild conjunctivitis disappears in a few days. 

If the secretion be more abundant and the lids perceptibly swollen, more 
active measures are required. 

Prof. Xoyes states that there is a variety of catarrhal ophthalmia neonatorum 
which requires active treatment. In the cases alluded to the ocular surface is but 
slightly involved, having little or no hyperemia, but the palpebral conjunctiva is 
hyperaemic and the fornix thickened and swollen. The swelling of the fornix is the 
most marked anatomical character. The secretion has a watery appearance, and 
the lids are but slightly tumefied. The cornea does not become hazy and the sight 
is not impaired, but the watery discharge and the viscid secretion on the borders 
of the lids continue for weeks, unless the case be promptly attended to. Noyes 
recommends for this form of catarrhal ophthalmia neonatorum the application sev- 
eral times daily of the boric-acid solution : 

R. Acidi borici, gr. xv ; 

Aquae destillat., ^j. — M. 

He adds : "But if a child is a month old and the discharge continue, and the fornix 
exhibit decided swelling, I have been obliged to use solutions of tannin and glycerin 
as strong as ^ij ad ^j before the condition would yield. I had tried nitrate of 
silver in mild solution, and, unwilling to make it more caustic, had taken a solution 
of tannin gr. x ad glycerinum ^j, but this had only a temporary good effect, and 
the disease was not subdued until the strong solution was applied. It was done 
every second day to the everted lid, and was of course quite painful." 

Purulent Ophthalmia Neonatorum; Gonorrhceal Ophthalmia Neonato- 
rum. — This is one of the most important diseases to which the neonati are 
liable, since, if not promptly and properly treated, it is very damaging to the 
eye, permanently impairing or totally destroying vision. It is produced by 
the lodgement in the eye of irritating matter, usually the gonorrhceal vaginal 
secretion of the mother. A minute amount of the virulent matter is sufficient 
to set up the inflammation. Becent observations seem to show that in a con- 
siderable number of cases the poisonous matter is received, not during birth, 
but in the washing, or subsequently from the fingers of the nurse or mother, 
or through the medium of soiled towels or linen. 

Andrews [New York Medical Journal, 1886) quotes the following table from 
Theremin, showing the time of commencement in 476 cases, as follows : 

First to fourth day after birth 57 oases. 

Fourth to eighth dav after birth 134 " 

Eighth to fourteenth da v after birth 94 " 

Later 104 " 




104 DISEASES OF THE NEWLY-BORN. 

When the disease begins subsequently to the first week after birth, it is evi- 
dent that the infection occurs post-natum, the poison being conveyed to the 
eyes through the soiled fingers or sponges or cloths employed in the nursery, 
as stated above. 

Gonorrhoeal ophthalmia neonatorum, as well as gonorrheal inflammation 
in other parts, is caused by a micrococcus designated the gonococcus. It 
occurs free and also enclosed in leucocytes in the various inflammations 
resulting from gonorrhoea, as well as in the secretions of gonorrhoea. It 
occurs, therefore, in the ovarian, perimetritic, tubal, arthritic, and conjunc- 
tival secretions and exudates having a gonorrhoeal origin, as well as upon the 
surfaces primarily affected with gonorrhoea. The gonococcus is generally 

Fig. 10. Fig. 11. 






Gonococci free. Gonococci -within a leucocyte. 

most abundant during the active stage of the inflammation, and not infre- 
quently it is associated with pyogenic cocci. 

In acute gonorrhoea usually no other or but few other bacteria except the 
gonococcus are observed ; but in chronic gonorrhoea of both sexes other 
microbes are commonly present in addition to the gonococcus. That the 
contagious and virulent property of gonorrhoeal pus is due to the gonococcus 
seems to be fully established, but were the action of this organism limited 
to cases of gonorrhoea, it would be less important as a pathological factor. 
Microscopic examinations show its presence in the pus of ophthalmia neona- 
torum, as well as in the vulvitis of childhood when of gonorrhoeal origin, 
and the intense inflammation and rapid destruction of sight in the former 
disease are believed to be due entirely to its agency. 

Dr. Gayet, professor of ophthalmic surgery, Lyons, France, says that the detec- 
tion of the gonococcus in infected pus is as simple and easy as that of albumen in 
albuminuria. He places a particle of pus on a glass slide, covers it by another slide, 
and presses the two together. They are then separated, and stained by dropping 
on them an alcoholic solution of methyl-blue mixed with an equal quantity of water. 
After two minutes the slides are washed freely with water, and each leucocyte is 
seen to have two, three, or four nuclei, " this being a special character of the disease, 
the increase in the number of nuclei heralding the approach of the gonococci, which 
will be observed as intensely blue spherical bodies in the interior of some of the 
leucocytes." * If the gonococcus be found in a single leucocyte, of course the diag- 
nosis is established. 

Stellwagon says : " The period of incubation after successful inoculation of the 
contagious material varies between some hours and days. The outbreak of the 
blennorrhoea follows the more quickly the more favorable are the conditions for 
the inoculation — i. e. the more powerfully the secretion is able to act." 

In most instances when infection occurs during birth some evidence of the 
disease appears as early as the second or third day. The inflammation is from 
the first severe. The conjunctiva, ocular and palpebral, is intensely hyper- 

1 La Province medicate; Lond. Lancet, June 18, 1887. 



OPHTHALMIA NEONATORUM. 105 

aeniic; chemosis soon occurs in most instances, and an abundant muco-purulent 
or purulent secretion flows between the lids mixed with tears. The inflam- 
matory hyperemia not only extends over the entire conjunctiva, but also to 
the connective tissue and the integument of the lids, causing in the latter a 
dusky or bluish-red tint. At a later stage the tint may be yellowish-red. The 
eyelids swell rapidly in consequence of the looseness of their connective tissue 
and the great amount of infiltration, so that they appear as projecting tumors 
pressing against each other and upon the eye, concealing the latter from view. 
The ocular conjunctiva, from the great amount of serous exudation under- 
neath, rises up like a circular wall around the cornea, which appears sunken 
in the centre of the swelling, and sometimes only its central part is visible in 
consequence of the bulging of the swollen conjunctiva over it. The palpe- 
bral conjunctiva is so swollen from the serous infiltration that it bulges for- 
ward on attempting to separate the lids, and eversion of them is liable to 
occur. From the great amount of tumefaction of the lids the palpebral fis- 
sure is closed, and the upper lid may project over the lower so as to nearly 
cover it. 

The danger to the eye results chiefly from the chemosis, or hard and tense 
oedema, of the subconjunctival areolar tissue, which by its pressure may ob- 
struct circulation. The eye is photophobic, tender to the touch, and the seat 
of severe pain. The intensity of the inflammation gives rise to active fever. 
The inflammation, having reached its maximum, soon begins to abate under 
correct treatment ; the bright-red erysipelatous hue of the lids changes to a 
bluish color ; the heat and tenderness abate. The secretion is abundant, and 
is constantly escaping from the conjunctival sac and flowing over the cheek, 
which is often reddened in consequence of its extreme acridity. If in the 
height of the inflammation we attempt to separate the lids, which are firmly 
pressed together not only in consequence of the great amount of tumefac- 
tion, but also from the spasmodic contraction of the orbicularis palpebrarum, 
the purulent secretion gushes forth, consisting of greenish or grayish pus — 
a thick liquid containing flocculi of epithelial cells and muco-pus. Occasion- 
ally, when the inflammation is intense, these flocculi contain also fibrin. The 
discharge, consisting chiefly of muco-pus mixed with tears, has a creamy 
appearance, but if the lachrymation be abundant it may resemble whey in 
color and consistence, especially in the declining stage. 

Purulent conjunctivitis usually begins in one eye, and, unless the sound 
eye be immediately and efficiently protected, the inflammation ordinarily soon 
attacks this eye. Of course both eyes may be simultaneously affected, but 
in a large proportion of patients there is an interval of a day or two in the 
commencement of the inflammation in the two eyes, that secondarily infected 
receiving the virus from the one first attacked. 

In the milder cases the inflammatory symptoms, the hyperemia, tumefac- 
tion, heat, and secretion, increase gradually, and it is not until the fifth or 
sixth day that they attain their maximum. In severe cases the symptoms 
reach their height by the close of the second or third day. The inflamma- 
tion, having attained its maximum, as indicated by the heat, swelling, and 
abundant secretion which wells up between the lids, soon begins to abate 
under correct treatment. But several weeks elapse before the normal state is 
restored, a simple catarrhal inflammation continuing after the purulent and 
infective secretion has ceased. 

Prognosis. — The danger to the eye depends upon the severity of the 
inflammation. If the chemosis be not great, and the swelling be more (Ede- 
matous than indurated, and the amount of secretion moderate, the eye is 
usually saved by timely and correct treatment. In severe inflammation 
characterized by great chemosis, hyperaemia and heat, and an abundant puru- 



106 DISEASES OF THE NEWLY-BOBX. 

lent discharge, the peril to the eye is imnlinent, since the inflammation is 
likely to extend from the conjunctiva to the cornea, and ulceration result. 
When the cornea becomes cloudy in places the danger to the eye is extreme, 
but the sight may be preserved, though abscesses and ulcers occur, provided 
that they are small and involve only a part of the cornea. Abscesses and 
ulcers near the margin of the cornea are less dangerous than those in the 
centre, but crescentic peripheral ulcers are of bad import, since they are 
likely to increase. If marginal softening and a central abscess or ulcer 
coexist, the sight will probably be lost. Of course the more quickly the 
inflammation is subdued the better the prognosis. 

At a meeting of the Blind Congress, held in Paris in 1879, F. Dumas stated that 
of 1178 blind patients whom he had treated, 1070 became blind from curable 
diseases, and of this number, 817, or 69 per cent., lost their sight from ophthalmia 
neonatorum. 

According to Horner, of the blind children treated in the institutions of Ger- 
many and Austria, from 20 to 79 per cent, lost their sight from this disease. 1 This 
was before the efficient prophylactic measures now in use were employed. 

Pretention. — Inasmuch as this malady is produced by the infective 
vaginal secretion of the mother coming in contact with the eye of the infant 
at birth, the use by the mother of antiseptic and disinfectant vaginal douches 
before and during parturition is suggested as the appropriate preventive 
treatment in case she have a muco-purulent discharge. For this purpose 
carbolized vaginal injections have been employed, with the result of diminish- 
ing the number of cases of ophthalmia neonatorum. 

Mules 2 advises the following very judicious and important preventive measures : 
" 1st. Cure all cases of chronic vaginal discharge before labor. 2d. Irrigation of 
the vagina during the second stage of labor when vaginitis is known to exist. The 
solution used for this purpose in Queen Charlotte's Hospital is corrosive sublimate 
(1 : 2000). The copious secretion of a clear vaginal fluid before and during labor, 
and the flow of the liquor amnii just before the birth, diminish the danger. 3d. 
Assist the foetal eyes to pass beyond the perineal edge without resting. This is 
easily done by hooking around the perineal edge with the fingers and drawing it 
down. 4th. By wiping the eyes with a clean cloth at birth of head. 5th. By in- 
stilling an antiseptic solution into the eyes at birth if the mother has a discharge. 
6th. Crede's method: to wash the face first, never in water in which the body has 
been washed. 7th. To retain one sponge or flannel especially for the child's face, 
and insist on scrupulous cleanliness. 8th. The nurse to wash her hands after 
adjusting the mother before touching the child. 9th. Not to expose child unduly 
to draughts, bright light, etc. 10th. To protect the child from flies with a thin veil. 
11th. To remove carefully the child from the presence of another similarly affected ; 
strict isolation of an infected case. 12th. To guard the one eye if the other be 
affected.'' The 10th and 11th rules are evidently applicable to cases in maternity 
wards, rather than to those in private practice. 

But in order to gain the highest degree of success by preventive measures it 
has been found necessary to treat the eyes of the infant immediately after birth, if 
there be the least reason to suspect the presence of an infective vaginal discharge 
in the mother, so as to destroy the poison if it have lodged in them. In the lying- 
in asylum, where, in consequence of the prevalence of gonorrhoea in the mothers, 
ophthalmia neonatorum of a severe form has been prevalent, antiseptic treatment 
of theeyes of all the newly-born has either entirely prevented this disease or ren- 
dered it of rare occurrence. To Crede of Leipzig more than to any other physician 
the credit belongs of having established this treatment. Its efficacy is now univer- 
sally recognized. 

Bathing the eyes of infants immediately after birth was previously practised by 
Abegg, who employed only water, and by Olshausen, who, through Yon Graefe's 
advice, employed a 1 per cent, solution of carbolic acid. Although this treatment 

1 Archiv fiir Gynakologie, 1883. 

2 Prize Essay, Manchester Chronicle, Jan., 1888. 



OPHTHALMIA NEONATORUM. 107 

diminished the number of cases of ophthalmia, it was far surpassed in efficiency by 
that recommended by Crede, who in 1880 began to treat the eyes of the newly-born 
in the following manner : The external surface of the lids was first washed with 
plain water ; the lids were then separated, and a single drop of a 2 per cent, solution 
of nitrate of silver was allowed to fall upon the cornea from the end of a glass rod. 
From 1880 to April 1, 1883, Crede treated 1160 infants in this way, and only 4 
became affected with ophthalmia neonatorum. This treatment by nitrate of silver, 
employed in other institutions in Europe and in this country, has been followed by 
signal success. Thus. Dr. Garrigues of New York employed Crede's treatment in 
the Maternity Hospital on Blackwell's Island, where ophthalmia neonatorum had 
previously been of common occurrence, and of 351 infants born consecutively " not 
a single one was affected." ] Dr. Garrigues adds that in these cases occasionally a 
thin discharge like serum followed the application of nitrate of silver, due appar- 
ently to its irritating action, and that the first cases in which he observed this dis- 
charge he treated with iced compresses and the instillation of a saturated solution 
of boric acid. But afterward he found that they quickly recovered without such 
measures. Occasionally so many drops of the nitrate were inserted by accident that 
a black ring was produced upon the eyelids, without any ill effect to the eye. Dr. 
Garrigues recommends Crede's method of employing a glass rod, to which a single 
drop of the solution adheres, so that there is no risk that more than this amount 
will be instilled. The application should be made as soon as the infant is removed 
from the bed to the lap of the nurse. She should first clean the eyelids and the face, 
and in washing them should be careful that none of the wash enters the eyes. A 
weaker solution of nitrate of silver has been employed without the good results 
which follow the use of the 2 per cent, solution. Crede made tentative use of 
borate of sodium (1 : 60), and found it greatly inferior as a preventive to the nitrate 
of silver. 2 

Preventive treatment of this kind should not be recommended in general 
midwifery practice, except when there is evidence or strong suspicion that the 
mother has gonorrhoea. Moreover, much can be done toward diminishing the 
number of cases of blindness resulting from ophthalmia neonatorum by dis- 
seminating among the masses a knowledge of the imminent danger to the 
sight of the newly-born infant when a purulent discharge occurs from its 
eyes, so that instead of employing domestic remedies the parents will seek 
at once the advice of the accoucheur or family physician. 

Treatment. — If proper measures be employed sufficiently early and per- 
sistently, the eye can nearly always be saved. Since this malady has a 
microbic origin, it is evident that an efficient germicide is required in the 
treatment — an agent that does not injure the eye, while it destroys the cause 
of the inflammation. Various germicides have been employed for this pur- 
pose, but the two which have been found safest, and at the same time most 
efficient, are corrosive sublimate and nitrate of silver. 

We again call attention to the necessity in this disease, more than in almost any 
other, of employing faithful and attentive nurses, who will carry out punctually the 
directions given. Two nurses are required — one to serve by day and the other by 
night — since it is essential that the eye be frequently cleaned and the secretion 
washed away. 

If the conjunctivitis be purulent, but mild, and attended by a slight dis- 
charge and little or no appreciable swelling of the conjunctiva, two drops of a 
2 per cent, solution of nitrate of silver should be instilled once between the 
lids, and the lids moved to ensure its flowing underneath them : 

R. Argent, nitrat , gr. vj ; 

Aquse destillat , gv. — M. 

In the subsequent treatment a strong solution of boric acid — some recom- 
mend a saturated solution — should be instilled every half hour, the lids being 

1 Amer. Journ. of Med. Sci., Oct., 1884. 2 Arch. f. Gi/nak., xxi. p. 193. 



108 DISEASES OF THE NEWLY-BORN. 

drawn widely apart. The frequent wide separation of the lids, which can be 
accomplished without undue pressure upon the eye, is useful in allowing the 
pus to escape, as well as in facilitating the application of the wash. I prefer, 
however, unless the disease yields quickly, the use of a weak solution of cor- 
rosive sublimate in place of the boric acid, employing the following formula : 

R. Hydrarg. chlor. corros., gr. j-ij ; 

Aquae destillat. , Oj .— M. 

The use of this mild solution of the sublimate every second hour after a 
single employment of the nitrate of silver usually suffices to cure mild cases 
in a few days. If the disease be more severe, but still mild, and accompanied 
by moderate tumefaction and a moderately increased secretion, a single daily 
application of the nitrate of silver suffices during the active period of the 
inflammation. In severe forms of the disease, accompanied by much tume- 
faction and the frequent gushing out between the lids of a thick, purulent 
secretion, the nitrate-of-silver solution should be used as often as every six 
hours. 

Dr. David Webster of the Manhattan Eye and Ear Hospital states that he has 
employed the nitrate of silver in these severe cases five times in twenty-four hours 
with great benefit. As regards the frequency of the application of nitrate of silver, 
and the time to desist from its use, Andrews writes : " The only guide which I know 
is the condition of the conjunctiva. When there is slight hypersemia only, the 
slough produced by the nitrate of silver requires a long time to be cast off,*' and it 
is very irritating. But if there be a more severe inflammation, with much swelling, 
the slough is thrown off in a few hours. The use, therefore, of nitrate of silver at 
intervals of a few hours should be practised only in the most severe forms of the 
inflammation, while in the milder cases it should be used only once or at long inter- 
vals. In the declining period of the disease the application of a solution of boric 
acid or a weak solution of corrosive sublimate, gr. 1 to the pint of distilled water, 
suffices to effect a cure. 

Umbilical Vegetations. 

Not infrequently small excrescences sprout out from the base of the 
umbilical depression at the time or soon after the fall of the cord. They 
have the appearance of those vegetations which arise from open sores. They 
have been designated in different languages by many appellations, as fungous 
excrescence of the umbilicus (Condie), excrescence of the umbilicus (Cooper, 
Foster), warty tumor of the umbilicus (Holmes), bourgonnement de Tombilie 
(Depaul), granulome de Tombilie (Dechamber), vegetation ombilicale (Guer- 
sant). 

The size attained by these growths is always small. Many of them are 
not larger than a pea in their greatest development. Their form appears to 
be determined in a measure by the external pressure. Some are rounded, 
and others are elongated or cylindrical. Their color varies from a pale red 
to a red of a deeper tinge, according to the degree of vascularity, and they 
are always moist. 

This outgrowth is distinguished by its irreducibility and its consistence. 
Digital pressure may cause it to disappear in the umbilical fossa : it dis- 
appears by depressing the floor of the fossa. It reappears in its entirety by 
the resiliency of the walls of the fossa as soon as the pressure is removed. 
It has the soft consistence of fungous tissue, so that it is depressed and flat- 
tened and its shape changed even by slight pressure. It arises in most 
instances from the inferior part or floor of the umbilical fossa, and it con- 
trasts in appearance with the cutaneous folds of the umbilicus by its softness 



UMBILICAL HEMORRHAGE. 



109 



and reddish tinge. It exhibits no tendency to ulceration or to hemorrhage, 
but a sanguinolent serum exudes from it and stains the linen unless the 
growth be small. The thin irritating discharge from the surface or base 
of the vegetation sometimes causes small excoriations upon the edge of the 
fossa. 

Progress. — This vegetation in the first days or weeks increases more 
rapidly than subsequently. It may attain half the size or the full size of a 
pea. or even a greater development, by successive sprouting of granulations. 
It may increase slowly during many weeks or months, or it may come to a 
standstill and show no tendency to diminish or atrophy. In time, according 
to several writers, it is likely to shrivel and skin grow over it, and thus be 
cured. But more frequently surgical interference is required. 

Treatment. — Cauterization by nitrate of silver acts slowly, but some- 
times destroys the vegetation if small. More efficacious and preferable 
treatment is to remove the growth by the scissors or ligature. Saint-Ger- 
main operates as follows : The fold of the skin surrounding the umbilicus 
is depressed, while slight traction is made on the excrescence by the forceps. 
The pedicle is then strongly tied by a silk thread previously dipped in a solu- 
tion of carbolic acid. Slight traction then suffices to remove the growths, 
and they sometimes drop off in the tying. After the removal a little iodo- 
form should be dusted into the umbilical fossa, and the umbilicus covered by 
a pledget of surgeon's lint retained in place by strips of adhesive plaster. 

Umbilical hemorrhage occurring at birth or soon after from too loose 
ligation of the cord, or from its laceration, is so well known and its cause 
so apparent that it need only be alluded to in this connection. Bouchut 
relates a case in which death took place from this cause even before birth. 
The child was attached to the placenta by a navel-string so short that it pre- 
vented delivery till it parted by the traction of the forceps. The bleeding 
from the umbilical vessels was so profuse that the child was pallid and life- 
less when born. 

But umbilical hemorrhage of the new-born sometimes occurs when the 
cord is properly tied, is uninjured, and the subsequent treatment of the um- 
bilicus is judicious and correct. The following table gives the ages at which 
this hemorrhage commenced in 99 cases : 



Age. No. 

On the 1st day 5 

" " 2d " 7 

" " 3d " 6 

" " 4th " . . . m 3 

5th to 7th day, inclusive 32 



Age. No. 

8th to 10th day, inclusive 25 

11th to 15th " " 16 

16th to 21st " " 4 

22d to 56th " " _^1 

99 



These statistics are interesting as showing the relation of the hemorrhage to 
the umbilical cord. In the 18 cases in which the hemorrhage occurred under 
the age of three days it appears from the records that the cord was attached. 
and the blood escaped from the walls of the umbilical fossa outside of the 
line of its attachment. Immediately after the fifth day, or after the time 
when the cord falls, there was a large increase in the number of cases, so 
that from the fifth to the fifteenth day after birth was the period of greatest 
liability to the hemorrhage. 

Etiology. — Since, as many observations have shown, in a large propor- 
tion of these hemorrhagic cases the blood has feeble coagulability, it seems 
probable that the umbilical vein and the umbilical and hypogastric arteries 
may not have been occluded by fibrinous coagula in at least some of these 
patients, as they commonly are in the healthy, and that the hemorrhage 
occurred in part from these vessels. This hypothesis is rendered more plan- 



110 DISEASES OF THE NEWLY-BORN. 

sible by the fact that from the general ill-health present in many cf these 
infants, probably the walls of the veins and arteries were lacking in contrac- 
tility, so that they remained more patulous than in robust and healthy infants. 
Hemorrhage from the umbilicus, as well as from other parts in the newly- 
born, must be referred to a faulty composition of the blood, especially its 
feeble coagulability, or to an abnormal state of the walls of the minute vessels, 
or to both these causes. The hemorrhage is sometimes referable to the 
hemorrhagic diathesis or haemophilia, which may be inherited or may result 
from obscure causes in children born of healthy parents. 

In the New York Infant Asylum a well-developed and apparently healthy 
mulatto woman gave birth to her first infant on November 30, 1886. She stated 
that her family were healthy and that the father of the child was also in excellent 
health. The birth was easy and natural, and nothing unusual was observed in the 
infant, which weighed nearly ten pounds, except a swelling from extravasated blood 
above and in front of the right ear. At 7 a. m. on the next day severe umbilical 
hemorrhage occurred, which was checked by styptics ; then slight epistaxis took 
place. At 11 a. m. bleeding from the navel returned, and appeared to come from 
several points at the margin of separation of the floor of the umbilicus from the 
cord. The tumor above the ear increased, purpuric spots appeared upon the integu- 
ment, and death occurred from exhaustion on December 2d. The infant lost one 
pound in weight during the two days of its existence. At the autopsy a few small 
superficial erosions could be made out in the umbilical fossa at the point of union 
with the cord. The umbilical vein, traced to the liver, and the hypogastric arteries, 
traced to the iliac arteries, contained no blood, were patulous, and apparently nor- 
mal. Extravasations of blood were found under the skin, in the abdominal cavity, 
and at numerous points in the lungs, etc. The organs had an exsanguine appear- 
ance, and everywhere the blood was without clots, its fluidity being a notable pecu- 
liarity. The cause of the haemophilia in this child was not apparent. Its parents, 
so far as could be ascertained, were healthy ; still, there may have been latent 
syphilis. 

Syphilis is one of the recognized causes of the hemorrhagic diathesis in 
the newly-born. In 1871, I was requested to visit a neonatus that was a 
bleeder, whose father was unmistakably syphilitic, and whose mother was 
suspected to have contracted syphilis from her husband. The child was 
fairly developed, and the cord separated on the sixth day. A constant oozing 
of blood from the navel commenced on the seventh day, on account of which 
I was summoned to the case. I finally succeeded in arresting the bleeding 
by the application of the plaster-of-Paris dressing, but immediately intestinal 
hemorrhage commenced, of which the child died in twenty-four hours. The 
parents were induced to take antisyphilitic remedies for a considerable time, 
and they have since had four healthy children. In another instance observed 
by me an infant, puny and apparently premature, was at birth observed to 
have several blebs of pemphigus, from which blood soon began to ooze, but 
the umbilical hemorrhage from which the child died did not begin until about 
the fourteenth day. 

Two elements or factors appear to be present in producing syphilitic 
hemorrhage in the newly-born. We have already alluded to abnormal fluidity 
of the blood, for when it escapes it does not coagulate or its coagulation is 
very inadequate. The other factor is abnormalities in the minute vessels. 
Many years ago the eminent obstetrician Sir James Y. Simpson of Edin- 
burgh met cases of hemorrhage in the newly-born which he attributed to 
inflammation of the vessels, arterial or venous, or both, from which the blood 
escaped. The inflammation, in his opinion, caused thickening and infiltration 
in the walls of the vessels, loss of tonicity, and consequently a patulous state. 
Simpson does not seem to refer in particular to the hemorrhage due to syph- 
ilis, but to that from other causes as well. Dr. Mracek, lecturer on syphilis 



UMBILICAL HEMORRHAGE. Ill 

in the University of Vienna, reported 19 cases of hemorrhagic syphilis in 
neonati. 1 None of the mothers had undergone antisyphilitic treatment. One 
of the infants was born dead, while the others lived from half an hour to 
forty-eight hours. The capillaries, the vasa vasorum, the venules, and arte- 
rioles were filled with morbid products, having caused local troubles of circu- 
lation and sanguineous effusions. 

Andronico states his belief that hemorrhages in syphilitic neonati are due 
not only to " diminished power of coagulation of the blood," but to a " vas- 
cular ectasis, particularly in the small cutaneous veins." Bleeding from the 
navel also sometimes occurs as a symptom or complication of jaundice. 
Writers who have collected records of this hemorrhage have remarked the 
frequent occurrence of the icteric hue both before and during the bleeding, 
even in those who do not present the history of syphilis. It is not improb- 
able that in certain instances the jaundice is hematogenous, arising from 
destruction of the red globules and liberation of the hsematin — a not unusual 
result of a profound dyscrasia even when there is no syphilitic taint. In 
other instances the jaundice proceeds from the liver, and the bleeding occurs 
from the altered state of the blood, which is produced by abnormalities in 
the liver or its appendages. 

Thus in at least five of the cases of umbilical hemorrhage collated by Jenkins 
the marked jaundice which was present was found to be due to congenital occlusion 
of the common bile-duct, and of course all the bile secreted which did not remain 
in the liver entered the blood. The biliary acids in the blood probably diminish 
the amount of its fibrin and increase its fluidity. 

Poor health in the mother and impoverishment of her blood during gesta- 
tion, whether from chronic disease, as tuberculosis, or antihygienic conditions, 
also cause impoverishment and increase the fluidity of the blood, and there- 
fore act to a certain extent as a predisposing, if not as a direct, cause of the 
hemorrhage. In exceptional instances no adequate cause of the bleeding 
can be detected either in the child or the health of its parents. 

Prognosis. — Statistics show that 5 in every 6 perish. The prognosis is 
most unfavorable when an obvious dyscrasia is present. Those who have 
jaundice or haemophilia with very few exceptions perish. Those are most 
likely to recover who have a healthy parentage, no obvious dyscrasia, and in 
whom the hemorrhage occurs late and is not profuse. The average duration 
of the hemorrhage in 82 cases in Jenkins's collection was three and a half 
days, the minimum being only three hours. Death usually occurs from ex- 
haustion. 

Treatment. — A compress of surgeon's lint or a sponge saturated with 
the liquor ferri subsulphatis should be firmly pressed over the umbilicus and 
retained by a bandage. If the bleeding do not cease, the umbilicus should 
be covered by a thick layer of plaster of Paris, supported by the hand until 
it hardens, and then retained in place by the bandage passing around the 
body. In the case related above, occurring in my own practice, this treat- 
ment arrested the bleeding from the navel, but it was followed by fatal 
intestinal hemorrhage. If the hemorrhage continue, the needles with lig- 
ature may be employed. Bouchut indeed states that this is the only effectual 
treatment. Two needles are passed through the umbilicus at right angles. 
and a waxed thread wound around each in the form of the figure 8. If the 
patient survive, the needles should be removed in four or five days and 
iodoform or a poultice applied. It is important, so far as time will permit, 
to treat the dyscrasia, and a laxative of calomel is often indicated, especially 
if constipation be present. A laxative is useful for its effect on the hepatic 

1 Berlin, klin. Woch., No. 46, p. 807, Nov. 15, 1886. 



112 DISEASES OF THE NEWLY-BORN. 

circulation and as a derivative. During the continuance of the hemorrhage 
four or five drops of brandy in breast-milk frequently administered are useful 
as a stimulant. 

Icterus, or a yellowish discoloration of the skin, is common in the newly- 
born. It has even been said that in its mildest form it is present in the 
majority of infants, and it arises from a considerable number of anatomical 
and pathological conditions. It occurs in its worst and most intractable form 
when there is congenital obliteration of the bile-ducts ; it is believed to occur 
sometimes in the youngest infant from the same cause as that which produces 
the usual form of adult jaundice — to wit, catarrh of the duodenum extend- 
ing by propagation into the bile-ducts and narrowing or occluding their 
lumina. Congenital syphilis is another cause, the icterus being probably 
produced by the newly-formed connective tissue which compresses the bile- 
ducts. The modus operandi of the causes related above is easily understood, 
but a large proportion of the neonati who have the icteric hue in a slight or 
mild form do not appear sick, and fully recover after a few days. The cause 
in such cases is probably of a trivial nature, else it would produce a more 
profound impression on the system. West says of these mild cases in which 
there is no appreciable impairment of the health that the yellow tinge of the 
skin comes on about the third day, deepens for a day or two, and subsides 
gradually, " the bowels acting properly and the urine not being high-colored : 
though to this condition the name of jaundice has been applied, it is yet no 
real jaundice, but is merely the result of the changes which the blood in the 
over-congested skin is undergoing, the redness fading, as bruises fade, through 
shades of yellow into the genuine flesh color." A yellow coloring of the skin, 
the result of cutaneous hyperemia, is not accompanied by the diagnostic 
signs of true jaundice, such as a yellow conjunctiva, clay-colored stools, and 
biliary coloring matter in the urine. Inasmuch as the liver and other internal 
organs are not concerned in producing this orm of icterus, West says it has 
been proposed to designate it by the term " local icterus." It would be 
interesting to ascertain in cases in which there is a deposit of pigment in the 
skin, while all the other organs, including the liver, are in their normal state 
and have their normal functional activity, whether there has been a cutaneous 
plethora due to late ligature of the cord. Zweifel states that the placenta 
before the uterus contracts after the expulsion of the child, and the cord is 
still beating, contains six ounces of blood, but if the cord have ceased to 
beat and the uterus be firmly contracted, half of this amount of blood, or 
three ounces, passes through the cord and augments to this extent the quan- 
tity of blood in the vessels of the foetus. Late ligature, therefore, when there 
is firm uterine contraction increases the fulness of the blood-vessels in the 
child, and, according to Park, babies with distended blood-vessels exhibit a 
more intense jaundice. 

H. Quincke advances another and in some respects a plausible theory of the 
etiology of the common form of icterus neonatorum. 1 He attributes the jaundice 
to the continued patency of the ductus venosus. Henry Ashby says 2 that in a 
minority of cases of jaundice of the new-born the clinical history or post-mortem 
examinations reveal the cause, as when it arises from congenital defects, syphilitic 
hepatitis or cirrhosis, septicaemia or haemaglobinuria. But the usual form of 
infantile jaundice, which begins on the second or third day, and commonly ends 
favorably, Ashby states, has nothing in common with the above fatal forms. He 
does not accept West's and Murchison's theory of a merely cutaneous icterus, and 
believes that Quincke's theory is the most plausible yet presented for consideration. 
The ductus venosus normally closes between the second and fifth days after birth, 
but if it remain pervious and the circulation from any cause be retarded, bile, 

1 Archivfur experimenteile Pathologie und Pharmakologie, xix. 1 and 2. 

2 Lond. Med. Times and Gaz., April 25, 1885. 



ICTERUS. 113 

according to the above theory, enters the branches of the portal vein and finds its 
way into the general circulation through the ductus venosus. In one case, says 
Ashby, an infant had jaundice from the second to the eleventh day, and at the 
autopsy the ductus venosus was large enough to admit an ordinary director. This 
theory also comports with the fact that feeble infants are more liable to become 
jaundiced than the robust, for those vascular canals which pertain to the foetal 
state and are obliterated after birth are more likely to remain a longer time pervi- 
ous in the feeble than the robust. 

Dr. Alois Epstein l made many experiments in order to determine whether bile- 
pigment occurs in the urine of icteric newly-born infants. He agitated the urine 
with lime-water, filtered it with alcohol, and added sulphuric acid. If bile-pigment 
be present, a green color results. He discovered in the urine a pigment in the crys- 
talline or amorphous state, and of a yellow or yellowish-red color. It occurred in 
the various forms of tufted needles or small tables, yellowish or brownish, and in 
yellowish-red amorphous granulations. Epstein was able to distinguish by chemi- 
cal reactions this pigment from uric acid and the urates. On further investigation 
he states that he found this pigment in all the organs, abundantly in the kidneys, 
and also in the blood. Does this pigment have an hepatic or heemic orgin ? Epstein 
is led by his investigation to believe that this crystalline or amorphous pigment 
results from changes occurring in the blood, and probably from the liberation of 
the coloring matter by the destruction of the red corpuscles, which Neumann, Kolli- 
ker, Denis, Hayem, and others have shown to occur so abundantly in the neonati. 

Epstein believes that any marked impairment of the important functions in the 
system tends to increase the destruction of the red corpuscles, the consequent release 
of its coloring matter, and the formation of the crystalline or amorphous pigment 
described above, which in icterus escapes into the tissues. Marked impairment of 
respiration, circulation, and calorification, artificial alimentation, prematurity, pro- 
tracted and difficult birth, taking cold, and similar agencies, in proportion as they 
impair the general health and produce perturbation in the system, increase the 
destruction of red corpuscles, and thereby act as causes of icterus. Epstein also 
mentions the well-known fact that the children of parents who have grave con- 
stitutional diseases or live under bad hygienic conditions are especially liable to 
become icteric, and that septic infection is an important cause of those alterations 
in the blood which give rise to icterus. 

The peculiar character of the blood of the newly-born is believed by good 
observers who have investigated this subject to predispose to the occurrence of 
jaundice. According to Hofmeier, the red blood-corpuscles in the neonati are more 
spherical than in adults, and do not show a tendency to form rouleaux. The white 
corpuscles are often more numerous than in adults ; they are viscid, deliquescent, 
easily destroyed, and have a tendency to aggregate in rouleaux. The investiga- 
tions of Ponfick and Silbermann 2 show that the red corpuscles of the new-born 
readily part with their coloring matter, the haemaglobin, under disturbing agencies, 
such as syphilis, burns, taking cold, injudicious nursery management, and even by 
the action of certain medicinal agents, as glycerin and pyrogallic acid. The red 
corpuscles which have lost their coloring matter by its transference to the plasma 
either disintegrate and disappear, or they appear under the microscope as pale 
rings which have been designated shadows. This transference of the coloring 
matter from the red corpuscles to the liquor sanguinis, and the disintegration of 
red corpuscles, which characterize the first few days of infant life, lead to an increase 
of hgemaglobin in the plasma (hsemaglobinhaemia) and of fibrin ferment. Silber- 
mann summarizes his views, derived from an examination of the character of the 
blood and the blood-changes occurring in the newly-born, as follows : " The blood 
of the newly-born holds corpuscles which vary greatly in size, aud also the so-called 
shadows : it is richer in fibrin-ferment than the blood of adults ; these peculiarities 
are due to the liberation of hgemaglobin and its transfer into the plasma : the rich- 
ness in fibrin-ferment of the blood of the newly-born predisposes to disease : all dis- 
ease-processes in the newly-born which involve great destruction of the albumen in 
the circulation are especially dangerous to life." These investigations relating to the 
blood will aid to an understanding of the views of Silbermann regarding icterus. 

1 "Ueber die Gelbsucht bei Neugeboren Kindern," Samrnlung Minischer Vwtrage, 
No. 80, 1880. 

2 "Zur Hiimatologie der Neugeborenen," Jahrbuchjur Kiriderhettkwnde, 1887. 



114 DISEASES OF THE NEWLY-BORN. 

Dr. Silberniann concludes l an elaborate paper on icterus neonati with the fol- 
lowing aphorisms : " 1st. Icterus of the newly-born is an icterus of absorption. 2d. 
The biliary engorgement has its seat in the biliary capillaries and the interlobular 
bile-ducts, which are compressed by the dilated branches of the portal vein and the 
capillary blood-vessels of the liver. 3d. This engorgement in the vessels is effected 
by the change in the circulation of the liver which occurs soon after birth, and is 
one of the indications of a general change in the blood-plasma. 4th. This change, 
which is induced by the destruction of many blood-corpuscles soon after birth, con- 
sists of a kind of blood-fermentation. 5th. The more feeble the infant the more 
intense will be the icterus, for in such a child the destruction of corpuscles, and the 
consequent blood-changes, will be much more decided than in a vigorous child. 6th. 
As the consequence of the destruction of so many red corpuscles there is abundant 
material for the formation of biliary coloring matter, and under the influence of the 
fermentation-process alluded to this accumulates in considerable quantity." There- 
fore, according to this theory, free coloring matter in the blood, derived from the 
abundant destruction of the red corpuscles which attends the first days of infancy, 
occurs in such quantity that it cannot be disposed of in the biliary secretion or 
otherwise eliminated, and is deposited in the tissues, causing the icteric hue. 

Birch-Hirschfeld 2 attributes icterus of the new-born to oedema of the capsule 
of Glisson, and consequent compression of the bile-ducts. This oedema he believes 
is due to diminution of pressure in the portal system consequent on section of the 
cord. 

That feebleness, insanitary conditions, and exposure are a cause of jaundice, 
however they may act to produce such a result, is shown by many observations. 
West, as we have stated above, describes a local or cutaneous icterus resulting from 
plethora of the skin, and having no special interest or importance, and a systemic 
or general icterus, which he states " does not affect perfectly healthy children who 
have been born at the full time, have been nourished exclusively at the mother's 
breast, and being sheltered from cold without being overburdened with clothing or 
confined in a vitiated atmosphere." In corroboration of this statement he alludes 
to the fact that in the Dublin Lying-in Hospital, where the utmost care is bestowed 
on the foundlings, icterus is rare, while it is so common in the Foundling Hospital 
of Paris that few escape. In the latter institution, as compared with the former, 
the exposures are much greater and the conditions as regards hygiene are greatly 
inferior. 

M. Bouchut says that icterus is observed in 80 to 90 per cent, of the new-born ; 
that Levret, Breschet, Billard, and Yalleix regard it as the result of ecchymosis of 
the skin following congestion — an opinion which he considers erroneous. He 
believes that it almost always results from a mild or severe hepatitis consequent 
on ligature of the cord. The ligature, he says, produces a mild inflammation which 
is propagated to the liver and causes obstruction of the bile-ducts. In his articles 
on hepatitis of the new-born he repeats his belief in this theory. 

The obvious inference from the above resume of opinions is that icterus 
neonatorum results from different causes in different instances, and that it is 
a mild or grave disease according to its etiology. The various causes admit 
of classification in two groups: 1st, the hsematogenous ; 2d, the hepatoge- 
nous. The haematogenous theory, which attributes the common form of 
icterus of the newly-born to the destruction of the red blood-corpuscles in 
the first days of life, and the escape of the coloring matter into the circula- 
tion, is advocated by such men as Billard. Virchow, Breschet, Porak, Violet, 
and Epstein. The hepatogenous theory has also advocates of equal reputa- 
tion. The etiology of this disease certainly requires further investigation, 
and when it is better understood it will probably be seen that distinct patho- 
logical states in the newly-born have been described under the term " icterus." 

Prognosis. — This depends on the nature of the cause as well as the 
present state of the infant. If the cause be susceptible of removal, as in the 
common mild form of icterus, a favorable prognosis is justified. The most 

1 Archivfiir Kinderheilkunde, 1887. 

2 Virchovfs Arch., 1882, Band lxxxvii. 






SEPTICEMIA. 115 

unfavorable cases are those in which there is absence of the biliary ducts or 
their permanent occlusion. In severe forms of the disease in which the con- 
nective tissue, the secretions, and transuded serum have the yellow hue the 
prognosis should be guarded. 

The common mild form of icterus, appearing on the second or third day 
after birth, disappears or is scarcely appreciable at the close of the second 
week. Severe icterus, continuing longer without any abatement in its inten- 
sity, is due as a rule to permanent anatomical conditions which prevent the 
flow of bile into the intestine, and is probably incurable. In these cases the 
stools remain clay-colored, the icterus increases, and vomiting may occur. 

The treatment is simple, and to a considerable extent expectant. Gen- 
tle friction over the liver may perhaps in some cases aid in removing the 
obstructive disease in the bile-ducts. The use of hydrarg. cum creta in 
small doses, as recommended by West, is of doubtful efficacy. It is evident 
that preventive measures are more important and more efficacious than the 
curative, since every measure which promotes a healthy parentage and the 
health and robustness of the infant tends to diminish the frequency of this 
disease. Those who, like Porak, believe that congestion of the skin at birth 
is a common cause of the simple form of jaundice recommend an early liga- 
ture of the cord, when the umbilical arteries are still beating or have just 
ceased to beat, since when the arteries are beating an equilibrium is main- 
tained in the circulation, whereas in a late ligature, when the uterus is firmly 
contracted and the arteries have for some time ceased to beat, a plethoric 
state of the vessels is more likely to occur. 

Septicaemia of the New-born. 1 

The manner in which sepsis or septicaemia occurs is sometimes obscure. 
Leube in 1878 relates two cases 2 in which the examination failed to disclose 
the source or mode of infection. He designates such cases cryptogenetic, 
expressive of the unknown or occult origin. Wunderlich and Schutzenberger 
allude to similar cases. But in septicaemia of the newly-born it is the com- 
mon and apparently correct belief that the septic poison usually enters the 
system at the umbilicus. The cases which I am about to relate are in har- 
mony with this theory. 

It is not my intention to discuss the nature of the septic poison, but there 
can be little doubt, from the examinations which were made, that in the fol- 
lowing cases it consisted of microbes and the toxines caused by them. 

Cases of septicaemia of the newly-born may be conveniently classified as 
follows : 

First Group. — Cases of umbilical phlegmon, which is a local septic dis- 
ease, the poison entering the system from an umbilical sore and being con- 
veyed by lymphatics. 

The New York Infant Asylum at Sixty -first street and Tenth avenue has, 
during the twenty-three years of its existence, been remarkably free from 
contagious and infectious diseases, but since September 1, 1887, seven cases, 
in which septicaemia was diagnosticated, occurred in new-born infants in the 
maternity ward of this institution. It is proper to state that at the same 
time diphtheria was epidemic in the asylum, and that five of the newly-born 
infants had diphtheria, the pseudo-membrane appearing in its usual situation 
on the pharyngeal, nasal, and laryngotracheal surfaces, and. in one or two 
of the patients, also lining the oesophagus. Moreover, two of the five infants 

iRead before the Pediatric Section of the New York Academy o( Medicine, Medi- 
cal News, Sept. 8, 1888. 

2 Deutsch. Arehiv fur klin. Med. 



116 DISEASES OF THE NEWLY-BORN. 

with diphtheria had umbilical phlegmon of a few days' duration, when the 
diphtheritic exudate appeared upon the faucial surface. 

The question is therefore a proper one, whether in these two cases the 
phlegmons were a local manifestation of diphtheria, or whether the umbili- 
cal phlegmon and diphtheria were distinct diseases having a different microbic 
origin. 

Case 1. — Victor M was born, after normal labor, on January 5, 1888, and 

the umbilicus was dressed with borated cottom The mother did well, and was able 
to leave her bed on the seventh or eighth day. Nothing unusual was noticed in the 
infant until January 11th, when a little suppuration was observed in the umbilical 
fossa at or around the point of attachment of the cord, but on examination the walls 
of the umbilicus were found thickened and indurated. The appearance indicated 
the commencement of an umbilical phlegmon, and the skin covering it was red as 
in erysipelas. The phlegmon extended in area until January 14th, when the thick- 
ening and infiltration reached to the distance of about one and a half inches in every 
direction from the umbilicus, so that the form of the phlegmon was circular or 
wheel-shape. Its thickness or depth near the umbilicus was perhaps three-fourths 
of an inch, but near its margin the thickening and infiltration were less. The pulse 
on the 13th varied from 132 to 144, and the rectal temperature was 101.8°. 

The case was carefully watched by Drs. Davis and Cook, the resident physicians, 
whose records I employ, and the faucial surface was daily inspected by them. On 
January 14th, the baby being nine days old, they observed for the first time the 
grayish-white exudate of diphtheria on each side of the fauces, and a day or two 
later also upon the Schneiderian surface, so closing the nostrils that respiration 
through them was impossible. The baby, on attempting to draw the nipple, became 
cyanotic and was obliged to relinquish its hold. During the 14th and 15th the tem- 
perature fell to 98.5° and 98°, the pulse was very feeble and too rapid to be counted 
accurately, and the respiration varied from 24 to 48. Death occurred on the 15th 
at the age of ten days. 

The autopsy revealed a diphtheritic pseudo-membrane upon the faucial surface 
on both sides, extending downward, so as to cover both surfaces of the epiglottis, 
the entrance of the larynx, and the laryngeal surface, completely concealing the 
vocal cords and the portion of the larynx above them. The trachea and bronchial 
tubes were free from the exudate. The lungs in nearly every part were thickly 
mottled with points of extravasated blood, and less abundant extravasations were 
observed in and upon other organs. The umbilical phlegmon, removed entire, and 
in a frozen state from the intensity of the cold in the dead-house, was sent to the 
laboratory of the College of Physicians and Surgeons, where it was carefully exam- 
ined by Dr. Prudden. He reports that the umbilical vessels were in their normal 
state, showing no evidence of disease, except the mouth of the umbilical vein or 
that portion of the vein which was next to and in immediate relation with the 
umbilicus. Plugging the mouth of the vein and extending a few lines along the 
lumen of this vessel was a thrombus or blood-clot, from which Dr. Prudden was 
able to obtain cultures, and in the culture-bed two forms of cocci were developed — 
to wit, the staphylococcus pyogenes aureus, occurring in the usual form in groups, 
and the streptococcus pyogenes, producing beautiful and delicate chains. The por- 
tion of the vein enclosing the thrombus or clot had preserved its integrity, so that 
the clot was entirely distinct from the phlegmon which covered the vein. It did 
not seem possible that microbes, toxines, or elements of the blood could pass from 
one to the^other, on account of the firm coats of the vein which were interposed 
between them. 

Portions of the phlegmon placed in culture media developed the same forms 
of cocci as those produced from the clot that plugged the mouth of the vein. We 
infer that the cocci were the septic agents, since no other cause of the septicaemia 
was discovered, and that they were received from the umbilical sore. Some entered 
the thrombus, and others, taken up by lymphatics, entered the tissues which sur- 
rounded the umbilicus and gave rise to the phlegmonous inflammation. 

It is easy to understand how micro-organisms may enter the umbilical 
vein after the fall of the cord, when there may not be complete closure of 
the mouth of the vessel. But it can scarcely be doubted that in the above 



SEPTICEMIA. 117 

ease, as well as in cases which I am about to relate, the septic infection took 
place through the raw and denuded surface of the umbilical fossa, the lym- 
phatics being the carriers of the poison. We know how frequently granu- 
lations sprout out from the umbilicus of the new-born, and wherever there is 
a surface denuded of cuticle from which these may arise there is a surface 
from which microbes or toxic agents may be absorbed. The umbilicus, too, 
is a receptacle in which microbes, conveyed in the floating dust of an apart- 
ment, in foul water used for bathing, in dirty sponges, or abdominal binders 
or umbilical dressings, would be likely to lodge. M. Bouchut, in his remarks 
on the fall of the umbilical cord, says : " Cords voluminous, soft, and plump 
dry slowly, and often suppurate at their base before they fall (les cordons 
volumineux, mous et gras, se dessechent lentement et suppurent souvent 
a leur base avant de tomber)." l With conditions so favorable for septic 
infection it is perhaps surprising that it does not more frequently occur, 
especially in hospital or asylum wards. 

The patient whose case I have related evidently had systemic infection. 
The numerous points of extravasated blood in the lungs and elsewhere 
showed this. But doubt must arise whether this general infection occurred 
from the phlegmon, in which there was intense hyperaemia and an active cir- 
culation, as shown by the inflammatory redness of the cuticle, or whether it 
resulted from and was connected with the diphtheria. But we will relate 
cases of systemic infection in which there was no diphtheria and in which 
the septic agent or agents entered the system through the umbilicus. 

The volume of the Transactions of the London Pathological Society for 
1879 contains the report of the committee appointed by that society to 
investigate pyaemia, septicaemia, and purulent infection. Their report is 
based on the examination of the records of 156 cases occurring in the London 
hospitals, and it throws light on the cause of hemorrhagic extravasations 
occurring in cases of septicaemia. They remark : " On microscopical examina- 
tion of different organs micrococci were found in all, or at least in some, of 
the viscera. They were nearly all in the blood-vessels, completely plugging 
the capillaries ; in masses which sometimes produced varicosities, or even 
rupture of the vessels, and extended into the contiguous tissues." 2 

Case 2. — Hilda M , born February 28, 1888, was plump and robust, weigh- 
ing eight pounds and seven ounces. The mother appeared to be well until March 
3d, when she had fever and symptoms which were apparently due to pelvic cel- 
lulitis, probably of septic origin. The infant was fretful on March 3d and 4th, 
and on March 5th a small ulcer was observed in the umbilical fossa. The skin 
surrounding the umbilicus, over an area the size of a silver dollar, had a deep- 
red color, and the tissues underneath, constituting the abdominal walls, were 
infiltrated and thickened. The phlegmon gradually extended in every direction 
from the umbilicus, so that on March 6th it nearly reached the ensiform cartilage 
above and the pelvis below. The fauces had been inspected daily, and at 5 p. m., 
March 6th, the grayish- white exudate of diphtheria was observed for the first time, 
covering the tonsillar portion of the fauces on each side. On March 7th the exudate 
had increased, the cry was hoarse, the fingers livid at times, and fluid regurgitated 
through the nostrils. The phlegmon occupied nearly the entire abdominal walls 
anteriorly. March 8th, surface cyanotic; respiration labored, and at times accom- 
panied by the expiratory moan ; a diphtheritic pseudo-membrane in the right nostril. 
Death occurred at 6.30 a. m., March 9th, at the age of ten days, on the fourth or 
fifth day of the phlegmon and on the third day of the diphtheritic exudate upon 
the fauces. The rectal temperature varied from 99.8° to 102.8° until the last day. 
when it was subnormal, being 96.6° ; the pulse varied from 99 to 112, and the res- 
piration from 40 to 60. Both the pulse and respiration gradually increased in 
frequency until death, this increase being probably largely due to the double pneu- 

1 Traite -pratique des Maladies des Nouveau-nis ) etc. 

2 Brit. Med. Journ,, January 24, 1880. 



118 DISEASES OF THE NEWLY-BORN. 

monia. The tincture of the chloride of iron in glycerin, brandy, and breast-milk 
were given internally, iodoform and carbolized iron applied to the umbilicus, and 
antiseptic sprays employed for the fauces and nostrils. 

Prof. T. M. Prudden kindly consented to conduct the autopsy, which was made 
with sterilized instruments and under conditions designed to prevent access to the 
body of adventitious germs. The following are his notes : 

Autopsy. — The umbilical orifice was covered by a dry, brownish scab, beneath 
which was a small, rough-edged cavity containing a yellowish semi-solid mass. The 
abdominal wall, for about three centimetres around the umbilicus on all sides, was 
hard, thickened, and dusky red. A section through the abdominal wall in the line 
of the umbilicus showed that the wall was thickened to about 1.5 centimetres imme- 
diately around the latter. 

Both the umbilical vein and the hypogastric arteries, to the distance of about 
1.3 centimetres from their attachment to the abdominal wall, were much thickened, 
red and hard, and their inner layers were converted into a soft, yellowish, friable 
material. Beyond this point all of these vessels were filled with blood-clots and 
appeared healthy. There was no peritonitis, and all of the abdominal organs were 
normal. 

The heart was normal. The pharynx, larynx, and trachea showed soft, reddish 
friable patches of diphtheritic membrane partially covering their free surfaces. 
This membrane did not extend into the bronchi. The lungs exhibited broncho- 
pneumonia in both lower lobes, with considerable consolidation. 

The microscopical examination of the parts about the umbilicus showed that at 
the point of attachment of the cord was a small pus-cavity whose walls were infil- 
trated with small spheroidal cells, with a few rod-like bacteria and with large 
numbers of spheroidal bacteria. Similar spheroidal bacteria were found in the 
purulent detritus contained in the cavity, as well as within the lumina, and infil- 
trating the walls of the adjacent ends of the umbilical vein and the hypogastric 
arteries. 

The tissues of the abdominal walls about the umbilicus were infiltrated with 
serum, fibrin, and a moderate amount of pus. Spheroidal bacteria were rather 
scantily scattered in the lymph-spaces of the swollen tissues, being most abundant 
near the umbilical vessels. 

Biological examination of the contents of the inflamed portion of the umbilical 
vessels showed the presence of several species of bacteria. The species which was 
by far the most abundant was readily identified as the staphylococcus pyogenes 
aureus. 

The anatomical diagnosis, then, is diphtheria of the pharynx, larynx, and 
trachea, with double broncho-pneumonia, localized septic inflammation of the 
umbilical vein and hypogastric arteries and of the abdominal wall surrounding 
them. 

As the evidence of local infection is so great, it seemed desirable to gain some 
data as to the purity of the air in the wards. Accordingly, such analyses as time 
permitted were made by Dr. T. M. Cheeseman, Jr., who presented the following 
report : "A biological examination of the air in the lying-in ward of the New York 
Infant Asylum, made on March 7, 1888, showed a very large number of living 
bacteria of many different kinds. Among them the staphylococcus pyogenes aureus 
was of frequent occurrence. A second examination, made immediately after the 
usual sulphur disinfection, showed a large number of living germs." 

Case 3. — Janse J , born January 3, 1888, was wet-nursed by its mother, 

and apparently did well until January 16th, when the attention of the resident 
physician was directed to it, and an umbilical phlegmon was discovered as large 
as a twenty-five-cent piece, the skin covering it being intensely red ; temperature 
98.5°. The dressing, after the discovery of the phlegmon, consisted in dusting with 
iodoform and the application of carbolized oil (one part of carbolic acid to twenty- 
five of sweet oil). January 17th, phlegmon not extending and its surface less red. 
The redness, thickening, and infiltration gradually abated, and on January 21st 
the patient was removed from quarantine. In this case there was no record of an 
umbilical sore ; the fauces remained normal, so that the diagnosis of diphtheria was 
excluded. The mother continued well. 

Case 4. — George C was born in the maternity ward January 14th. On 

January 25th the nurse observed a small vesicle upon the border of the umbilicus, 
and removed the cuticle covering it. Some hours afterward the attention of the 



SEPTICEMIA. 119 

resident physician, Dr. Davis, was called to it, who found thickening and infiltra- 
tion of the umbilical wall, most marked on the side which had been occupied by 
the vesicle. The same treatment was employed as in Case 3. The records of Jan- 
uary 26th and 27th state that the redness and infiltration are abating, and on the 
29th the umbilicus had returned to the normal state. 

Case 5. — John S , born October 14, 1887, the mother being a healthy prim- 

ipara. The child was well developed, weighing nine pounds and four ounces. The 
cord fell on the sixth day, and a small ulcer with indurated edges was observed in 
the umbilical fossa at the point of attachment of the cord. The induration in and 
around the umbilicus increased slowly until the ninth day. On the ninth day the 
child was restless, and on examination the ulcer was found enlarged and surrounded 
by a zone of inflamed tissue half an inch in width. The inflammation, accompanied 
by the usual infiltration and swelling, gradually extended, so that on the 15th the 
diameter of the inflamed area was two inches. The ulcer had also increased. On 
the twentieth day after birth the ulcer had attained the diameter of two inches and 
the depth of three-eighths of an inch, but the induration had begun to abate. From 
this time improvement was progressive, and no notes were taken after the twenty- 
fourth day. The rectal temperature, ascertained each day from the ninth to the 
twenty-fourth day, varied from the normal to 102°. During the active period of 
the phlegmon it was usually from 100° to 101.5°, and the emaciation was pro- 
gressive, the loss of weight being estimated at two pounds. The treatment con- 
sisted in dusting with iodoform and the use of a compress of absorbent cotton 
soaked with a solution of carbolic acid. During the second week, under the advice 
of the attending physician, Dr. George P. Fowler, calomel was also dusted on the 
sore. On the twenty-fourth day the infant was removed to the Post-Graduate 
School, and its subsequent history is unknown. The mother had no unfavorable 
symptom. 

Case 6. — Joseph D , born October 22, 1889, well developed, weighing seven 

pounds thirteen ounces. The cord fell on the eighth day, leaving a small ulcer at 
its point of attachment with an indurated border. Two days later, the tenth day 
after birth, the ulcer had increased slightly, being one-quarter of an inch in diameter. 
The surrounding tissues to the distance of one inch were thickened and indurated 
from inflammation. At no time was the temperature above 99.1°, and the child, 
though restless, nursed well. The tumefaction and hardness surrounding the um- 
bilicus remained about the same until the sixteenth day, after which they gradually 
abated. The ulcer had healed at the end of the fourth week. The mother on the 
third day after confinement had elevation of temperature which continued four 
days, and six weeks after the birth of the child she had diphtheria in the usual 
form. During the same month — October — twenty-seven obstetrical cases were 
under observation, but all except this patient convalesced without any unfavorable 
symptom. 

Second Group. — Cases in which septicaemia probably occurred by absorp- 
tion of infectious matter through the umbilical vein. 

Case 1. — In May, 1884, an infant died of septicaemia at the New York Infant 
Asylum at the age of fifteen days. It was apparently well until about the close 
of the first week, when the umbilicus was observed to be raw, and a slight oozing 
of a puriform liquid occurred from it. During the second week the abdomen was 
hard and tender, and peritonitis was diagnosticated. The cord fell on the seventh 
day. During the second week the abdomen was apparently painful ; the tempera- 
ture three days before death was 100.6°, and two days before death 102.4°. Exam- 
ination of the chest gave a negative result. The post-mortem examination was 
made by Dr. W. H. Welch, now professor of pathology in Johns Hopkins Univer- 
sity. The abdomen contained six ounces of turbid serum with flakes of fibrin. 
The portion of the peritoneum covering the umbilical vein and along the under sur- 
face of the liver, especially at the transverse fissure, was covered with fibrin, but 
the peritoneum generally did not exhibit any notable hyperamiie or inflammatory 
appearance. Lymphatic vessels filled with purulent-appearing substance could be 
seen in the under surface of the diaphragm, showing in what way septic infection 
extends along the lymphatics. The lymphatics of the diaphragm open upon the 
pleural surface, and it is probable, had the patient lived longer, that septic pleuritis. 



120 DISEASES OF THE NEWLY-BORN. 

perhaps on both sides, would have occurred. The umbilical vein was filled from the 
umbilicus to the transverse fissure of the liver with a grayish softened detritus con- 
sisting of broken-down thrombi with a considerable proportion of pus. Softened 
thrombi could be traced the entire length of the umbilical vein, the walls of which 
were thickened and infiltrated from inflammation. No thrombi were seen in the 
portal vein or vena cava ; the pericardium contained more than the normal amount 
of serum with flakes of fibrin ; hemorrhagic points were observed in the posterior 
portions of the lungs under the endocardial surface, under the peritoneal coverings 
of the kidneys and mucous covering of the calices. The mother did well, giving 
no evidence of disease of any kind. 

Case 2. — This infant, born in the New York Infant Asylum, the date not being 
given, was well developed at birth, weighing eight pounds six ounces. When four 
or five days old it became feverish, the temperature rising to 104.6°. The cord 
separated at the usual time, and the umbilicus seemed healthy. At the age of two 
weeks an abscess appeared upon the scalp, another upon the back, and another 
upon the nates, which raised the suspicion of septic poisoning. At the age of four 
weeks orchitis on one side occurred, which continued three weeks, when it abated. 
AVhen the child was two months old a prominence appeared about half an inch 
above the umbilicus, which Dr. Parker, the resident physician, punctured, and bile 
flowed from the incision. Subsequently the incision closed, and bile flowed from 
the umbilicus, and continued to flow until death, which occurred, in a state of much 
emaciation and weakness, at the age of eight months. 

At the autopsy, made by Prof. Welch, remains of old abscesses were found upon 
the trunk and extremities, and an abscess holding four drachms of pus was found 
over the occipital bone. Underneath the abscess the bone was carious and the dura 
mater thickened. The umbilical vein was much larger than normal, its walls being 
infiltrated and thickened, and its lumen of about twice its usual diameter. It 
contained thickened bile. One of the branches of the vein, traced into the liver, 
opened into an abscess the size of a walnut which contained thickened pus with 
bile. The abscess was in the right lobe near its posterior border. The mother 
remained well. 

Case 3. — Lizzie C , born September 21, 1887, robust, weighing eight pounds, 

seemed well, taking the breast and having normal evacuations, until September 
28th, when she became restless and refused the breast. Her temperature, rectal, 
was 101.4°, and her respiration was accelerated and accompanied by the expiratory 
moan. September 20th, temperature 103.6° ; respiration accelerated and painful 
and abdomen distended ; no cough. The diagnosis of peritonitis, probably of septic 
origin, was made, but the umbilicus was of usual appearance, and the desiccation 
and fall of the cord seemed normal. The elevation of temperature, even to 104.4°, 
the distention of abdomen, and the hurried respiration with expiratory moan con- 
tinued until death, which occurred September 30th. 

At the autopsy three ounces of sero-purulent liquid containing flakes of fibrin 
escaped from the peritoneal cavity. All the abdominal organs were covered by a 
fibrinous exudation, the intestines being matted together by it. The umbilical vein 
was pervious ; it contained clots of blood and dirty-looking pus, but the umbilicus 
was apparently normal. A segment of the aortic valve was thickened and rigid, 
and attached to it was a fibrinous mass. The appearance indicated an endocarditis 
of slight extent. Under the microscope the walls of the umbilical vein presented 
their normal appearance, but its dirty-looking and disintegrating contents probably 
contained septic matter. The hepatic cells exhibited the peculiar cloudiness observed 
in protracted febrile diseases. Otherwise the organs seemed healthy. In this case 
also the mother remained well. 

Case 4.— A. B , born January 22, 1868 ; father healthy, but mother stru- 
mous, though in good health during her gestation. The infant, born after an easy 
labor, was apparently well at birth and it had sufficient breast-milk. AVhen it was 
thirteen days old I was requested to visit it, as it had not been doing well, and I 
found it suffering from subcutaneous abscesses. Abscesses had occurred upon both 
legs, in the chest-walls of the right mammary region, in and around the metatarso- 
phalangeal articulations of one foot, and over both knee-joints. The child had 
fever, but its respiration was good until February 8th, when it suddenly had a 
severe attack of dyspnoea, which continued until death, ten hours subsequently. On 
the following day Dr. Charles A. Leale and myself made the autopsy. The body 
was moderately emaciated. About one ounce of pus escaped from the right knee- 



SEPTICEMIA. 121 

joint. Pus was also found in the joint of the great toe on one side, and about two 
ounces in an abscess under the right pectoral muscle. A thin layer of tissue con- 
stituted the internal wall of the abscess, so that had life been prolonged a few days 
it would probably have broken through into the pleural cavity. The right lung 
was completely collapsed, and the pleura lining this lung, as well as that lining the 
thoracic walls on the same side, was covered by a fibrinous exudation. The left 
lung contained the normal, or perhaps more than normal, amount of air, so that it 
filled the pleural cavity, but there was a small amount of fibrinous exudate upon 
the parietal pleura in this cavity. 

The trachea and lungs attached were removed, and on practising insufflation of 
these organs air escaped from three openings in the posterior part of the right lung. 
These openings, through which air had passed into the pleural cavity, causing 
collapse of the entire lung, were found on examination to have been produced by 
small abscesses in the tissue of the lung near its posterior surface. By the rupture 
of these abscesses the pus which they contained escaped into the pleural cavity, 
producing intense general pleuritis and pneumothorax. Numerous minute ab- 
scesses were found in both lungs, but only the three alluded to had been ruptured. 
It seemed certain that had the patient lived longer other abscesses would have 
ruptured. 

Case 5.— In the following case bacteria were found making their way along the 
umbilical vein at a distance from the umbilicus, and also in the tissues involved in 
the umbilical phlegmon. Those in the phlegmon were apparently derived from the 
umbilicus and conveyed by the lymphatics. This case, therefore, might be placed 
in the first group as well as the second : 

Anne was born in the New York Foundling Asylum on May 18, 1888. A 

few days after birth, and before the cord dropped, the umbilicus was observed to be 
foul from secretion or exudation in it, indicating a sore at the base of the fossa. On 
the seventh day an umbilical phlegmon was noticed, small and confined to the 
umbilical walls. Three white patches were also observed on the roof of the palate 
near the velum, not raised and apparently not diphtheritic, resembling superficial 
ulcers. All the infants born in the maternity ward of the Foundling Asylum were 
receiving Crede's treatment, designed to prevent purulent conjunctivitis, one drop 
of a 2 per cent, solution of nitrate of silver being instilled between the eyelids of 
each eye. Although this child was thus treated, she had a pretty active purulent 
conjunctivitis of the left eye, to which our attention was now called for the first 
time on the seventh day. Crede's treatment was immediately reapplied to this eye, 
one drop being introduced between the lids. This was followed by the corrosive- 
sublimate treatment recommended by the late Prof. Samuel D. Gross. A solution 
of the sublimate, two grains to the pint, was dropped between the lids every hour 
to two or three hours, four or five drops being used each time. The conjunctivitis 
rapidly abated, and in less than a week had nearly or quite disappeared. But the 
phlegmon presented a very angry appearance, and the umbilical walls were greatly 
swollen, red, and denuded of cuticle. The inflamed area had a diameter of about 
four inches, with the umbilicus at the centre. Iodoform and carbolized oil were 
applied to the umbilicus and iron and stimulants given internally. The rectal tem- 
perature, taken May 26th, was 98°. Death occurred May 27th. 

Autopsy, thirteen hours after death. — Body well nourished ; no rigor mortis ; no 
external lesion except the umbilical ; the phlegmon definitely outlined and hard, its 
central half brown and dry ; the infiltrated abdominal wall had twice its normal 
thickness ; peritoneal surface of phlegmon congested and adherent to omentum ; 
from this point to the transverse colon was a leash of dilated vessels, one inch in 
width and three or four inches in length ; peritoneum injected, and a few petechia? 
observed in the parietal layer and the mesentery ; mesentery deeply injected ; liver 
and spleen normal; kidneys soft and flabby; points of hemorrhagic pneumonia in 
all the pulmonary lobes ; abundant tenacious mucus covering the surface of the 
stomach and intense injection, showing acute gastritis ; cerebral pia mater finely 
injected, but without exudation ; brain normal. Diagnosis : umbilical phlegmon, 
peritonitis, acute gastritis, hemorrhagic pneumonia. 

Microscopical and Biological Examination, by Prof. Prudden at the Laboratory 
of the College of Physicians and Surgeons. — The small ragged cavity at the umbili- 
cus contained a moderate amount of pus, cell-detritus, and enormous numbers of 
bacteria of various forms, the spheroidal form predominating. The tissues of the 
abdominal wall about the umbilicus were infiltrated with fluid, fibrin, and pus ; 



122 DISEASES OF THE NEWLY-BORN. 

scattered about in this exudation-mass were small spheroidal bacteria. The hypo- 
gastric arteries and the umbilical vein were plugged with clots extending from one- 
half to three-quarters of an inch from their origin ; their walls were greatly thick- 
ened by infiltration with inflammatory exudate. Both in the lumina of these vessels, 
along the sides of the clots, and in the lymph-spaces in their walls were enormous 
numbers of small spheroidal bacteria. These bacteria were present in the umbilical 
vein beyond the limits of the clots in the direction of the liver. 

The kidneys showed moderate parenchymatous degeneration. The consolidated 
areas in the lungs were due to a nearly complete filling of the air-spaces and the 
smaller bronchi with blood. 

Cultures made from the inflamed tissue about the umbilicus and from the edges 
of the sloughing cavity showed several species of bacteria common in the air and in 
the faeces of children. In addition to these the staphylococcus pyogenes aureus was 
present in large numbers. A set of cultures from the inside of the umbilical vein, 
at a little distance from the sloughing cavity, revealed the presence of staphylococ- 
cus pyogenes aureus and streptococcus pyogenes, together with other forms. Cul- 
tures from the liver showed large numbers of staphylococcus pyogenes aureus, with 
considerable numbers of a stout bacillus similar to one abundant in the sloughing 
cavity. From the lung-tissue from the consolidated regions enormous numbers of 
bacilli developed in a nearly pure culture, which corresponded in its biological 
characters to the bacterium lactis aerogenes of Escherich. 

Remarks. — This child would thus seem to have been the victim of infection 
with the ordinary " suppurative bacteria" and with faeces. We infer that fecal matter 
in some way came in contact with the umbilicus. 

Third Group. — It seems probable that in exceptional instances the septic 
poison of the newly-born is received in other ways or other channels than the 
umbilical vessels. 

If septicaemia of the newly-born occur through absorption from an umbili- 
cal sore, may it not also from a sore located elsewhere ? Decomposing and 
disintegrating animal tissue, wherever located, may be the source of septic 
infection. Moreover, medical literature contains histories of epidemics of 
puerperal fever in which newly-born infants perished with what was often 
designated erysipelas, but which the modern pathologist would unquestion- 
ably designate septicaemia. The disease which I have described as um- 
bilical phlegmon, a local septic disease, was commonly regarded by the older 
writers as a form of erysipelas. Dr. Condie, in his Treatise on Diseases of 
Children, described in the following lines what we would now designate 
septicaemia. 

" Erysipelas of infants very commonly occurs during the prevalence of epidemic 
puerperal fever. Children of mothers who become affected with the fever are often 
born with erysipelatous inflammation ; others are attacked almost immediately after 
birth. Whether in these cases the disease is to be referred to a morbid matter 
applied to the skin in the womb, or to the same endemic or epidemic influence 
which gives rise to the disease of the parent, it is difficult to say. According to 
M. Trousseau, infantile erysipelas is principally observed when puerperal fever 
prevails in the wards of the lying-in hospitals of Paris." 

The late Dr. Folsom of this city furnished me with the following sketch of cases 
which occurred in his practice and that of his partner: "About the year 1840, 
being then in practice in New Bedford, Mass., I was called to visit a man who 
complained of pain in the knee. The next morning he was easier, but the follow- 
ing evening his symptoms grew worse, and, as I was engaged in a case of obstet- 
rics, my partner. Dr. E. C, now dead, visited him. At my call, next morning, I 
unexpectedly found the patient dying. The disease was obscure, and at the autopsy 
next day no lesion was discovered. In making the examination Dr. C. pricked his 
finger, and, experiencing little inconvenience from it at first, he attended a case of 
confinement on the following morning. A few hours subsequently he was taken 
sick, and I took charge of the lady, who died in three days, having the tumid abdo- 
men and symptoms of childbed fever. The infant of the patient" was seized when 
two days old with erysipelas appearing on the face and in spots on the trunk and 
limbs, and terminating fatally in one day. Dr. C.'s finger became swollen and 



THRUSH. 123 

painful, and the lymphatics of the forearm and arm became inflamed, presenting 
red lines, and the axillary glands suppurated. Though feverish and much pro£ 
trated, there was no appearance of erysipelas in his case. In about two weeks he 
resumed practice, and, as at that time physicians in this country were not fully 
aware of the danger of communicating puerperal fever, he attended two, three, or 
four obstetrical cases each week until the number reached fifteen. All the mothers 
died with symptoms of metro-peritonitis, and all the infants had erysipelas, com- 
mencing on the face or some part of the body, generally on the second or third day 
after birth, and in all terminating fatally within a week. This sad record was 
finally ended by the doctor temporarily retiring from practice." 

What better description could be given of a malignant form of septic infec- 
tion ? It will be observed that the unfortunate doctor did not have erysipe- 
las, but inflammation of the lymphatics occurring from the poisoned finger, 
and the infant who first contracted the disease and died of one day's sickness 
exhibited red spots upon the trunk and limbs of an erysipelatous appear- 
ance. Did the doctor poison the mothers and infants at the same time by 
his digital examinations ? did he poison the mothers by his infected fingers, 
and they in turn poison the babies through the placental circulation ? For- 
tunately, the profession are now fully aware of the danger of septic infection, 
so that no intelligent and prudent accoucheur would attend an obstetrical 
case after making a post-mortem examination or visiting a case of puerperal 
fever without change of clothing and thorough personal disinfection, and con- 
sequently cases belonging to our third group are much more rare than 
formerly. 

It is evident that septicaemia of the newly-born might be prevented in a 
large proportion of instances by proper antiseptic dressing of the navel. 
Boric acid is a feeble and inefficient antiseptic, and the borated cotton which 
was employed in dressing the navel when the cases in the maternity ward 
occurred which have been related above was inadequate to prevent infection. 
Probably umbilical phlegmon might be prevented in maternity wards by 
bathing daily the umbilicus with a solution of the sublimate, gr. ij to the 
pint, or the use of some other antiseptic. 

When an umbilical phlegmon has commenced we have employed dusting 
with iodoform, the application to the navel every two hours of carbolized 
sweet oil (1 : 30), and bathing the navel with a solution of corrosive subli- 
mate, two grains to the pint of distilled or boiled water. In some of the 
cases thus treated when the phlegmons were small the patients gradually 
recovered, but in most of the cases the phlegmons were so large, and the 
microbes at such a distance from the umbilicus in the tissue of the abdomi- 
nal wall, that antiseptics applied upon and around the umbilicus were not 
curative. Newly-born infants are probably too young and feeble to be satis- 
factorily treated by incisions in the phlegmon and the application of antisep- 
tics to the incised surfaces, else this treatment might be more efficient than 
treatment without such incisions. 



Thrush. 

The terms thrush, sprue, and muguet — the last from the French — are 
synonymous. They are used to designate a form of inflammation of the 
mucous surfaces the peculiar feature of which is the presence of points or 
patches of a curd-like appearance on the inflamed surface. The usual seat 
of thrush is the buccal membrane, but occasionally it occurs on the faucial 
and oesophageal surfaces. It is very rare in the subdiaphragmatic portion 
of the digestive tube, but a few such cases have been reported by Billard 



124 DISEASES OF THE NEWLY-BORN. 

and others. It never occurs upon the membrane of the nostrils, larynx, or 
bronchial tubes, and it very seldom occurs upon any other surface without 
also being present upon the buccal mucous membrane. Thrush, then, is a 
stomatitis, pharyngitis, oesophagitis, or gastro-enteritis with the additional 
element which I have mentioned. 

Causes. — The younger the infant the greater is the liability to thrush 
when the causes favorable for its occurrence are present. It is therefore 
common in infants under the age of six weeks, and a majority of the cases 
occur under the age of six months. The common causes of this disease are 
such as ordinarily develop a stomatitis, prominent among which are improper 
feeding, indigestion, gastro-enteritis, and the cachectic state, whether arising 
from prematurity, congenital weakness, or enfeebling diseases. The most 
common and obvious of the causes alluded to is the use of indigestible and 
improper food, which produces a gastro-intestinal catarrh, soon followed by 
stomatitis. Thrush is therefore a common disease among foundlings in insti- 
tutions where these unfortunates are received, since they not only breathe 
an atmosphere which is often impure, but are deprived of the mother's milk, 
and are so frequently given a diet which is a poor substitute for it. Infants 
in crowded tenement-houses of the cities and in destitute families, whose 
diet is often very unsuitable, are much more liable to thrush than infants 
well fed and well cared for in well-to-do families. 

In infants under the age of three months the cause of thrush is often 
mild, and soon removed by better hygienic conditions and improvement in 
the diet. An improper diet for a few days, or a slight gastro-intestinal catarrh 
which quickly subsides when the cause ceases, is sufficient to develop the 
disease. In the newly-born the frequent use of sweetened carminatives or 
of sweetened dietetic mixtures administered by the nurse often gives rise to 
sprue, which ceases when these drinks are withheld and a proper mouth-wash 
applied. But after the age of six months, and especially after the age of 
one year, the condition giving rise to sprue is much more serious. After the 
age of twelve months sprue is comparatively rare, and when it does occur it 
is usually in the later stages of a protracted and exhausting disease ; and in 
such cases it is an unfavorable prognostic sign. Under such circumstances 
it occurs even in childhood, youth, and adult life, and is justly regarded as a 
complication of grave import. Thrush, being a parasitic disease, is com- 
municable by contact, like the parasite skin diseases. Thus in the wards of 
a foundling asylum the tip of a nursing-bottle used by different foundlings, 
if not properly cleaned after its use, may be the means of communicating it. 
Thrush is so common in young infants when the buccal surface is in a state 
favorable for its occurrence that it is probable that the specific germ may 
also be received from the atmosphere. 

Anatomical Characters. — The first stage of thrush is that of simple 
inflammation of the mucous surface. The mixed salivary and mucous secre- 
tions in the mouth, which are normally alkaline, become acid. There next 
appear upon the mucous surface minute semi-transparent points or granules, 
which, increasing, soon become white and opaque. Some of them remain as 
points, while others, extending and perhaps coalescing with those adjoining, 
form patches of greater or less extent. The white points or patches are 
unequally elevated. Their central part, which was first formed, is most 
raised, while their circumference projects but little above the epithelium. 
Their highest elevation is ordinarily not more than a line above the surface. 
They resemble closely in color and consistence portions of curdled milk, and 
the nurse often mistakes them for such and neglects to call attention to the 
state of the mouth. They are readily detached by a little force, when the 
mucous membrane underneath is seen to be in its integrity. Their color in 



THRUSH. 



125 



Fig. 12. 



the tirst days of sprue is white, and sometimes this color continues. In 
other eases they assume, if the disease be protracted, a yellowish hue. 

Their true nature, long unknown, was finally revealed by microscopy. 
They consist in part of epithelial cells and in part of a vegetable growth. 
This parasite is the O'idium albicans, discovered by Berg of Stockholm, but 
more fully described by Gruby and Charles Robin. The roots of the parasite 
are transparent, and they penetrate the epithelial layer, sometimes even to 
the basement membrane. The branches arising from these rootlets divide 
and subdivide at an acute angle, and under the microscope are seen to con- 
sist of elongated cells with one or two nuclei. The branches or the mycelium 
is formed by the union of the cells at their extremities. Numerous spherical 
or ovoid spores are also present surrounding the mycelium and covering the 
epithelial cells. Haller states that he has identified this parasite with the 
O'idium lactis, which occurs in milk undergoing acid fermentation. The 
spores are primarily developed, and are found in the scraping of the mucous 
surface in the vicinity of the patches of sprue. In two instances in examin- 
ing the product of thrush removed from the oesophagus I found that the 
parasitic plant was the Penicillium glaucum or a conferva closely resem- 
bling it. 

We have described the ordinary form of thrush as it occurs in young 
children, but if the patches are of large size and abundant, and the buccal 
surface generally of a deep-red color, there is usually some severe prostrating 
malady on which the thrush has supervened. 
We have already alluded to the fact that 
thrush in its severe forms often complicates 
protracted gastro-intestinal catarrh or chronic 
pulmonary malady. Hence some writers 
who have observed thrush in foundling 
asylums regard it as one of the most serious 
maladies of early life. Valleix, in a book of 
more than seven hundred pages relating to 
the diseases of children, devotes more than 
one-third of it to the consideration of mu- 
guet, but those pathological conditions per- 
taining to the digestive apparatus which 
most observers regard as distinct from 
sprue, though sustaining a causal relation to 
it, he includes in the description of muguet. 
Of 24 cases the records of which he pub- 
lishes, 22 died, but their death was in most 
instances due to gastro-intestinal inflamma- 
tion, which the author describes under the 
term " muguet." Most writers properly re- 
strict, as stated above, the term thrush, 
sprue, or muguet to those inflammations 
of mucous surfaces which are accompanied 
by the peculiar parasitic outgrowth, regard- 
ing the severe subdiaphragmatic inflamma- 
tions from which Valleix's patients died as 
distinct from muguet, though sustaining a 
causal relation to it. In the post-mortem 
examinations which I have witnessed in the 
Nursery and Child's Hospital, Infant Asylum, 
and Foundling Asylum of New York City, 
of those having thrush at the time of death, who for the most part have been 




Pavement epithelium covered by 
spores of the O'idium albicans (Ch. 
Robin). 



126 



DISEASES OF THE NEWLY-BORN. 



infants under the age of three months, I have frequently found evidences of 
inflammation in every division of the alimentary canal. The parasitic growth 
was, however, never seen below the oesophagus. Parrot, however, states that 
he has discovered it, in rare instances, in the larynx, stomach, and intestines. 
Symptoms. — Thrush in itself does not give rise to any symptoms except 
those that pertain to the surface which is the seat of the parasitic growth. 
Other symptoms are not referable to it, but to the diseases in the course of 
which it is developed and which it complicates. Sprue is preceded and 
accompanied by the symptoms of gastro-intestinal catarrh or some other 

Fig. 13. 




Spores and branches of the O'idium albicans (Ch. Robin). 

disease which affects the digestive apparatus and causes acidity of the buccal 
surface. The mucous membrane, upon which the cryptogam is soon to 
appear, becomes red, hot, tender to the touch. As we have stated above, it 
gives the acid reaction more or less marked to litmus-paper, and in the scrap- 
ing from its surface placed under the microscope the spherical or oval spores 
of the O'idium albicans are observed. A few hours later small white points 
appear, at first scarcely visible, produced by the cryptogamic growth and the 
epithelial and amorphous matter adherent to it. 

These points enlarge, and within a day or two present the well-known 
appearance of small masses or patches of curdled milk. They are fragile 
and readily detached, but are soon replaced by others so long as the cause 
continues. In the worst forms of thrush the surface upon which the crypt- 
ogam appears not only presents the ordinary features of severe inflammation, 
such as heat, redness, and tenderness, but it is sometimes deficient in the 
natural secretion, so as to present a dry or parched appearance. In these 
severe cases there is usually in young infants obstinate and protracted 
inflammation of the subdiaphragmatic portions of the digestive tube. The 24 
cases related by Valleix, alluded to above, 22 of which were fatal, were of 
this kind. But the gravity of such cases, in which thirst, anorexia, restless- 
ness, vomiting, diarrhoea, and progressive emaciation occur, is due, as stated 
above, to the primary disease which has produced the conditions favorable 
for the occurrence of sprue. If sprue occur, its symptoms should be dif- 
ferentiated from the more pronounced symptoms of the disease which it com- 
plicates. 



THRUSH. 127 

Diagnosis. — This is not difficult so far as relates to thrush of the buccal 
surface, for simple inspection reveals its presence. If a particle of one of 
the patches be placed under the microscope, the mycelium and spores of the 
Oidium albicans are readily detected. Only the inexperienced could mistake 
the diphtheritic exudate for the growth of sprue or vice versa. The diph- 
theritic pellicle penetrates the mucous membrane, from which it is detached 
with difficulty, leaving underneath a raw and bleeding surface, and it is 
thick and tough, contrasting in these particulars with the product of sprue. 
Enlargement of the cervical glands is also common in diphtheria and is absent 
in sprue. 

Particles of coagulated casein upon the tongue and gums bear a close 
resemblance to the patches of thrush, but their relation to the mucous mem- 
brane is simply that of contact, and they are removed by a spoonful of water. 

Prognosis. — The duration of thrush varies according to the duration and 
nature of the primary disease which it complicates. In young infants who 
have indigestion or slight gastro-intestinal catarrh it is quickly cured by 
appropriate local treatment if the nutriment given be of the proper kind and 
the stomach and intestines be restored to their normal state. On the other 
hand, thrush occurring in the course of chronic and highly debilitating dis- 
eases is not so quickly cured, or if cured is likely to return. It does not 
materially increase the gravity of the malady in the course of which it 
occurs, but when it complicates a chronic disease it indicates a reduced state 
of the system, an impairment of the general nutrition, which if it continue 
is likely to end fatally. 

Sprue is a bad omen if the tongue and buccal surface be dry, hot, and 
highly injected, the coating of the tongue of brownish color, the infant fret- 
ful, with the appearance of suffering in its physiognomy, and having progres- 
sive loss of flesh and strength. Such symptoms indicate in most instances a 
fatal form of gastro-intestinal catarrh. On the other hand, in young infants, 
since indigestion and slight gastro-intestinal derangements are adequate to 
cause an acid state of the buccal surface and the development and extension 
of the Oidium albicans, the large majority of the cases of thrush in which 
the general condition is good and the stomatitis mild are quickly cured by 
appropriate treatment. 

Treatment. — Since the common cause of thrush in infancy is the use of 
indigestible or improper food, the physician should ascertain the nature and 
mode of preparation of the infant's diet, and, if it be faulty, should direct 
one that is better. If the infant be bottle-fed, the mother's milk or that of 
a wet-nurse should, if practicable, be substituted for the artificial feeding ; 
but if this be impossible, a diet should be selected which bears the closest 
possible resemblance to the mother's milk in digestibility and nutritive 
properties. 

There is often in thrush an excess of acidity in the digestive tube, and 
an alkali is required. Trousseau recommends the addition of saccharate of 
lime to the milk. Children with this disease should also be taken from filthy 
and damp apartments to those in which the air is pure and dry. and their 
mouths and persons should be kept clean. 

The remedy in common use in the treatment of thrush, and which is 
usually effectual, is borax. This, if applied sufficiently often to the affected 
membrane, not only destroys the parasitic growth, but prevents its reproduc- 
tion. It is commonly employed with honey or in a powder with sugar or 
dissolved in water. The officinal mel boracis, consisting of one part of boras 
to eight of honey, is so much used in families that it may be considered 
almost a domestic remedy. There is, however, an objection to using any 
application for the removal of thrush which contains either sugar or honey. 



128 DISEASES OF THE NEWLY-BORN. 

since either substance remaining in the mouth would rather promote the 
growth of the parasite. Still, it is desirable to employ a wash of such con- 
sistence that it will remain a longer time in contact with the buccal surface 
than will a simple solution in water. I know no better vehicle for the borax 
than glycerin, which has the advantage of consistence, does not undergo any 
chemical change, and has no unpleasant flavor. The borax may be used dis- 
solved in glycerin, with or without some flavoring ingredient : 

R. Sodii borat., gj ; 

Glycerini, £ij > 

Aquse, Jj. — Misce. 

This wash should be applied four or five times daily, and continued for a 
time after the disease has disappeared from sight, since the roots of the plant 
must be destroyed or the branches are rapidly reproduced. It should be 
applied by a camel's-hair pencil or with a soft cloth upon the finger or a 
stick. It should be so freely used in extensive and severe forms of the 
disease that the infant will swallow some, since the entire oesophagus may be 
also the seat of sprue in such cases. In the intervals between the applica- 
tions of borax, if the buccal surface be hot, dry, and tender, so as to increase 
the fretfulness of the infant, it is well to use mucilaginous washes, as the 
mucilage of acacia or mallows. If the disease continue notwithstanding the 
use of the borate of sodium, the acidum boricum may be properly employed 
with it, as in the following formula : 

R . Sodii borat. , 

Acidi borici, da. ^j ; 

Glycerini, jjij ; 

Aquae anisi, q. s. ad ^iv. — Misce. 

For a mouth-wash, applied hourly or every two hours. 

In many cases, however, the treatment of thrush is of less importance 
than that of the disease which the thrush complicates. The remedial meas- 
ures which I have mentioned then become subordinate to those employed for 
the graver disease. When this disease is relieved and the general health 
improves, thrush is more easily and permanently cured than during the state 
of feebleness and ill-health. 



CHAPTEE III. 
DIAEEHCEA, CONSTIPATION, AND TETANUS OF THE NEW-BOEN. 

Diarrhoea of the Newly-born. 

The colostrum, or the first secretion of the mammary glands after partu- 
rition, contains more oily matter and sugar than occur in the subsequent 
secretion. In consequence of this peculiarity in its composition the colos- 
trum has a laxative effect by which the meconium is expelled. If the mam- 
mary glands continue to secrete colostrum after the first week, diarrhoea is 
likely to result. A more common cause of diarrhoea of the newly-born is the 
employment of various sweetened mixtures by mothers or nurses in the belief 
that the breast-milk is inadequate, or they are employed for the purpose of 
relieving the supposed colicky pains whenever the baby frets. Cane-sugar 
added to the various mint teas not only gives rise to diarrhoea, but also in 
time to more or less gastro-intestinal catarrh and stomatitis, with the occur- 
rence of sprue. Sprue is more common in the newly-born than at any other 
period of life, and it can usually, according to my experience, be traced to 



DIABEHCEA AND CONSTIPATION. 129 

the use of improper sweetened mixtures. The infant immediately after birth 
may be given a little sweetened water or a teaspoonful of sweet oil to aid in 
the expulsion of the meconium, but subsequently, in the great majority of 
cases, no carminative or nutritive mixtures are required. The breasts of the 
mother if she have the usual health furnish all that is needed. The neonatus 
requires almost no nutriment during the first three days, and the breasts fur- 
nish but little during this time, but frequent traction upon the nipple pro- 
motes the mammary secretion, and after the third day, in ordinary cases, 
sufficient nutriment is obtained from the breasts to supply the wants of the 
system and promote a healthy growth. If what is natural were left to itself, 
and no artificial measures were employed, the result in most instances would 
be good ; but the unfortunate practice of filling the infant's stomach with 
various admixtures disturbs normal digestion, impairs the appetite, causes 
colicky pains, vomiting, and diarrhoea, and, if persisted in, gastro-intestinal 
catarrh. In many cases green fermenting and unhealthy stools cease, and a 
more normal state of the digestive apparatus is produced by forbidding the 
use of superfluous and injurious food and drinks which had been given to 
supplement wet-nursing in the mistaken belief that more food was required. 
Food in excess, even if it be of the proper quality or it be breast-milk, usu- 
ally causes diarrhoea if it be not vomited, since, not being digested, it under- 
goes fermentative changes, and acts as an irritant until it is expelled. We 
have treated of this subject elsewhere. 

Diarrhoea in the newly-born, whatever its cause, should be immediately 
arrested. After the meconium is removed by the action of the colostrum, 
three daily evacuations from the bowels are sufficient. A larger number is 
usually attended with loss of flesh and strength. The use of sweetened mix- 
tures, which nurses are in the habit of administering when infants are not 
well, as catnip, fennel, or aniseed tea, we repeat, must be strictly forbidden. 
A mother with a sick and fretful' infant usually applies it to the breast too 
frequently, even every half hour during the day. This should also be strictly 
forbidden. The infant, like the adult, should take food at stated intervals, 
so that the digestive organs may have some respite from the task of diges- 
tion. The application of the new-born infant to the breast twelve times in 
twenty-four hours is sufficient for its nutrition, and the mother's health is 
better preserved and her milk of better quality than when she is deprived 
of the needed rest by more frequent suckling. If the infant be unfortunately 
deprived of breast-milk and be bottle-fed, the utmost care is required in the 
selection and preparation of the food, as well as in determining the amount 
of food to be given and the frequency of feeding. Facts relating to this 
important subject have been presented in preceding pages. 

If the diarrhoea do not cease by the use of the proper diet given in suit- 
able quantity at proper intervals, medicinal treatment is needed. I have 
found the following prescriptions very useful for the diarrhoea of infants 
under the age of one month, as well as for those that are older: 

R . Bismuthi subnitrat. , sjiij ; 

Pepsini puri in lamellis, &j. — Misce. 

Give as much as goes on a ten-cent piece before each suckling or feeding. 

R. Bismuthi subnitrat., oil > 

Wyeth' s elixir of digestive ferments, or Fairchild' s 

essence of pepsin, oj ; 

Aquae destillat., ^iij.— Misce. 

Shake bottle. Give 20 drops before each suckling or feeding. 

9 



130 DISEASES OF THE NEWLY-BORN. 

A clyster of bismuthi subnitrat., gr. v to x ; resorcini, gr. iij ; aquas 
purge, ^j — Misce, is also frequently useful for the diarrhoea. 

Constipation of the Newly-born. 

In the infant constipation results from several different causes. The most 
serious and obstinate form of it, to which the term obstipation is more appro- 
priately applied, arises from intestinal malformations. In rare instances con- 
genital obstruction occurs in the small intestines. It is sometimes produced 
by cystic tumors or twisting of the intestine. Congenital stenosis occasion- 
ally occurs at the ileo-cascal orifice. Thus in the Transactions of the London 
Pathological Society for 1870 is the history of a case in which there was such 
narrowing of the ileo-csecal orifice, believed to be congenital, that a No. 9 
catheter could barely be passed through it. The patient lived until his 
thirty-second year, but throughout his life suffered from constipation and 
colic. After his death the ileum next to the ileo-caecal valve was found to 
have a diameter of seven inches, while the large intestine was much atrophied 
and its entire lumen contracted from disuse. Occasionally the stenosis occurs 
a little above the ileo-cascal orifice, and rarely in the duodenum at the point 
of union of the pancreatic or bile-duct with the intestine. The obstacle in 
some instances appears to be hypertrophied valvulae conniventes, the edges 
of two opposite folds being more or less adherent. Such congenital intestinal 
obstructions— whether, as is probable, produced by inflammations in the foetus 
or from simple perverted nutrition ; whether arising from the syphilitic 
cachexia or other cause — of course retard the evacuations according to their 
location and the amount of closure. The same degree of stenosis in the colon 
or rectum obviously causes a more constipating effect than in the small intes- 
tines, since the latter have more mobility than the former and their contents 
are more liquid. 

But the most common of the congenital obstructions in the intestines 
occur from malformations of the rectum. These malformations vary con- 
siderably in different cases. They may be classified in at least four different 
groups : 1st. The anus may appear normal, but instead of the normal rectum 
two cul-de-sacs are present, representing the upper and lower ends of the 
rectum, and connected by an occluded segment of the rectum or by a firm 
fibrous cord. 2d. The anus is absent, and the rectum has a fistulous opening 
in the perineum, or through the scrotum in the male or vulva in the female. 
In the embryonic development the outlet of the rectum was formed too near 
and encroached upon the sexual apparatus. 3d. The anus is absent and there 
is no external fistulous opening representing the anus, but the rectum opens 
at some point upon the mucous membrane of the genito-urinary apparatus. 
4th. Anus absent and the entire lower part of the rectum obliterated. The 
upper portion of the rectum terminates in a cul-de-sac in the neighborhood 
of the promontory. Some of these malformations do not prevent the dis- 
charge of fecal matter, but when there is closure of the rectum and no fistu- 
lous opening, of course no evacuation of the intestines can occur unless relief 
be obtained by surgical measures. In the ordinary form of occlusion a por- 
tion of the rectum is represented by a cord, or a firm, unyielding septum shuts 
off the lower part of the rectum from that above, so that defecation is impos- 
sible. The infant with this serious malformation takes the breast for a time 
like other infants, but the intestines soon become distended with fecal matter, 
and restlessness from the distention and vomiting occur. The only mode of 
relief is by an incision or puncture through the obstruction ; but a large pro- 
portion of infants with this obstructive malformation die whether operated on 
or not. The surgical treatment of these cases will be discussed elsewhere. 






BIABBHCEA AND CONSTIBATION. 131 

The great length of the sigmoid flexure in infancy, and the curvatures 
which occur in consequence, more in number than in older children, tend to 
retard the descent of fecal matter and promote constipation. In the adult 
numerous depressions and inequalities in the colon retard the downward 
movement of the intestinal contents, but in infancy the surface of the colon 
is comparatively smooth and even, and the detention, so far as any exists, 
occurs from the curvatures or loops, which are sometimes twisted partially 
on their axes. The sigmoid flexure is so long in infants under the age of 
ten. and especially of six months, that the curvatures usually lie in part to 
the right of the median line, and even in the right iliac fossa. Those who 
have witnessed the post-mortem examinations of young infants in the asylums 
find no difficulty in accepting the statements of certain writers that the cur- 
vatures or loops in the sigmoid flexure, which sometimes extend as high as 
the umbilicus and laterally to the right iliac fossa, cause habitual constipa- 
tion in some infants. 

Occasionally in young infants, as well as in those who are older, the intes- 
tines act sluggishly from insufficiency of food. Thus the infant sometimes 
hangs an unusually long time on the breast, and the mother or wet-nurse 
believes it to be a hearty nurser, when there is really a deficiency of milk, 
and the stools are scanty and infrequent from lack of material : under such 
circumstances the infant is restless when away from the breast, or, not being 
fed, loses flesh, and soon has the appearance of one in ill-health. These symp- 
toms disappear upon the supply of a more liberal allowance of food of proper 
quality. 

Again, a constipated state of the bowels occasionally occurs in infants 
who nurse heartily and seem to obtain a sufficient quantity of milk ; and the 
cause of it appears to be in the state of the digestive organs, and not in the 
milk. We find now and then that breast-milk has a constipating effect, 
although we discover nothing in the mother's diet or health to cause this 
result. The comparison of ordinary breast-milk with colostrum may furnish 
an explanation of the constipation under such circumstances. Colostrum is 
known to be more laxative than ordinary milk, and it differs from it chemi- 
cally in containing more butter, sugar, and salts. Hence the theory seems 
plausible that when breast-milk is constipating these elements occur in less 
than the normal quantity, and we will find that treatment suggested by this 
theory tends to obviate the constipation. 

Constipation has also been attributed to a deficiency in the intestinal 
secretions and to too great viscidity of them from lack of water. Deficient 
peristalsis, whether from congenital weakness or other cause, also leads to 
constipation. The use of starchy foods without sugar or with but little sugar 
also sometimes has a constipating effect. 

Gautier of Geneva, Switzerland, states that an anal fissure is a common 
cause of constipation, whether in the newly-born or older infants. If such a 
fissure be present, pain in defecation might instinctively lead the infant to 
resist the desire to evacuate the bowels and to postpone the act, so as to estab- 
lish a constipated habit; but if such fissures are common in this country, 
except in the syphilitic, they have escaped our notice. 

Finally, constipation has a tendency to perpetuate itself, since retained 
feculent matter becomes more consistent and firmer, and the contractile power 
of the muscular tissue becomes weakened by over-distention. 

Symptoms. — When there is a mechanical cause of scanty and infrequent 
defecation, the acuteness of the symptoms and the suffering are usually pro- 
portionate to the degree of obstruction. In cases of complete obstruction of 
the intestines, as in imperforate rectum, fecal accumulation occurs above the 
obstruction. Under such circumstances distention of the abdomen, vomiting. 



132 DISEASES OF THE NEWLY-BORN. 

fret-fulness apparently from the abdominal pain, 'and progressive loss of flesh 
and strength, indicate the serious nature of the disease. 

In constipation from other causes — that is, without obstruction except 
such as arises from fecal accumulation — the condition of the infant may 
attract little attention at first ; but if it do not have proper evacuations, it 
soon begins to suffer in its health. Fretfulness, an unhealthy physiognomy, 
vomiting, and more or less fever occur until the patient is relieved of the 
ailment. 

The treatment of constipation in the new-born, as well as in older chil- 
dren, we will consider elsewhere. 

Tetanus Neonatorum. 

Several years ago Humboldt wrote that there is no subject in the whole 
range of scientific investigation more obscure than the causation and spread 
of the acute infectious diseases. Humboldt did not live long enough to 
witness the wonderful discoveries by the microscope and the light thrown by 
this instrument on the obscure subject which puzzled him whose investiga- 
tions embraced the whole universe. 

In the decade commencing with 1880 the bacillus which causes tetanus 
was discovered by the conjoined labors of distinguished bacteriologists, 
among the earliest and most successful of whom was Nicolaier, so that the 
bacillus was at first designated by his name. In November, 1886, Bosenbach 
produced tetanus in two guinea-pigs by inserting under their skin small por- 
tions of gangrenous material from the ulcer of an individual having tetanus. 
He also demonstrated the fact that the bacillus of Nicolaier is capable of 
causing tetanus in animals. These discoveries excited great interest, and 
were soon followed by the important chemical researches of Brieger, by 
which he isolated a toxine occurring in the cultures of the bacilli of tetanus 
and generated by them. This toxine has the formula C I3 ,H 30 ,Az 2 ,O 4 , and 
it produces tetanus when injected under the skin of an animal susceptible to 
this disease, while the bacilli deprived of this toxine by filtration are inert. 
Brieger also states that he extracted from the same cultures two other toxines 
of great activity, which he designates tetanotoxine and spasmotoxine. The 
setting free of these toxines was accomplished, according to Brieger, with 

the disengagement of sul- 
Fig. 14. phuretted hydrogen. Bac- 

teriologists describe the 
* A* bacillus of tetanus as hav- 

o o^ ing twice or thrice the 

^ '** length of the tubercular 

a - J 3 ^ bacillus, but thicker and 

£ vj straighter, and knobbed or 

'/ ^ S* enlarged at one extremity 
A so as to be designated pin- 

B shaped. Bonome, among 

The tetanus bacillus. others, made microscopic 

examinations and cultures 
of this bacillus obtained from the wounds or sores of human beings, horses, 
and sheep. Among micrococci and bacilli of various sizes and forms he 
observed the constant presence of the fine bristle-shaped, pin-headed bacillus 
identical with that described by Nicolaier. Bonome endeavored in vain to 
obtain pure cultures of the bacillus, and concluded that it did not thrive 
except in company with the germs of putrefaction. 

The recent cultivation of the tetanus bacillus in the laboratory of the 




< 



TETANUS NEONATORUM. 



133 



Fig. 15. 



chemist is a fact of great interest, and one that throws light on the causa- 
tion of tetanus, whether in the infant or adult. The process is described by 
Mr. R. T. Hewlett, demonstrator of bacteriology in King's College, in the 
London Lancet, July 14, 1894, as follows : " In order to obtain the chemical 
products for inoculation and other purposes, the bacillus of tetanus may be 
grown without the use of any complicated apparatus in an atmosphere of 
hydrogen, in the following manner : Yeast-flasks of about 90 c. c. capacity 
are made use of, and are filled three parts full with a 2 per cent, grape- 
sugar bouillon. The neck is corked with a perforated rubber cork through 
which a glass tube passes to the bottom of the flask, projects two inches 
above the rubber cork, and is plugged near its top with cotton wool, care 
being taken that the plugs are loose enough to allow air to pass freely. The 
whole is sterilized and inoculated and allowed to remain. The glass tube, which 
passes through the rubber cork, is then connected with a Kipp's or other 
hydrogen-generating apparatus by means of a rubber tube, and a current of 
hydrogen is passed through the flask. The 
hydrogen bubbles through the bouillon and 
escapes by the lateral tube. After the gas 
has escaped for about an hour, a small 
capsule containing mercury is applied to 
the end of the lateral branch, so that the 
open end just dips below the surface of the 
mercury, and the tube which passes through 
the rubber cork is sealed off in the blow- 
pipe flame, care being taken that all the air 
has been expelled from the flask by a free 
current of hydrogen. The flask, with the 
capsule of mercury applied to the end of 
the lateral branch, can then be placed in 
the incubator. Thus the mercury forms a 
valve ; air cannot enter, while gases formed 
by the growth of the organism have free 
exit." By this simple apparatus the bacillus of tetanus is grown in the 
flask of the chemist in an atmosphere of hydrogen. Air or oxygen is 
totally excluded, this microbe being anaerobic. 

Prof. "Win. H. Welch of Johns Hopkins University, in his address before 
the American Medical Association at Newport, June 28, 1889, said : "Among 
the pathogenic bacteria which have their natural home in the soil the most 
widely distributed are the bacilli of malignant oedema and those of tetanus. 
I have found some garden-earth in Baltimore extremely rich in tetanus bacilli, 
so that the inoculation of animals in the laboratory with small bits of this 
earth rarely fails to produce tetanus." 

The fact, as stated by Prof. Welch, that the bacillus of tetanus has its 
natural home in the soil, throws light on many interesting observations which 
have been recorded in the literature of tetanus. Several years ago that large 
part of New York Island now occupied by the Central Park, and between the 
Central Park and the Hudson River, was occupied by the laboring class, 
living in shanties of the simplest construction. The streets were not sew- 
ered, and refuse matter from the shanties and stables, the two being often 
built together, was dumped upon the open spaces. The stables were occupied 
by horses and cows. As might be expected, these simple and primitive domi- 
ciles and their surroundings were filthy as were the habits of most of the 
families. Tetanus neonatorum was not uncommon in this part of ihe island. 
I recollect that in one of the shanties in this locality two infants died o\' this 
disease at an interval of about fifteen to eighteen months. These observa- 




134 DISEASES OF THE NEWLY-BORN. 

tions correspond with the fact that many have stated that the bacilli of tetanus 
thrive best among the germs of putrefaction and in a soil mixed with the 
excreta of horses. 

Another fact, showing that the soil is the natural home of the tetanus 
bacillus, was observed some years ago by surgeons of Bellevue Hospital. 
The surgical patients entering this hospital from a certain part of Long 
Island were very liable to have tetanus at the time of entering or to manifest 
it soon after. 

There are or have been localities in every climate where tetanus neona- 
torum was the most prevalent and fatal of the infantile diseases. The bleak 
and barren islands of Hiemacy and St. Kilda in the far north, nearly destitute 
of vegetation and with guano for fuel, probably containing the tetanus 
bacillus, the dirty negro cabins of the Southern States, Fulda, Demerara, and 
Bombay, may be mentioned among the places where tetanus neonatorum is 
or has for lengthened periods been so common as to materially check the 
increase of population, and afford evidence of the correctness of the theory 
that the natural home of this bacillus is the soil. 

Several cases have recently been reported throwing light on the etiology 
and pathology of tetanus. Paul Berger states that he requested the late 
distinguished surgeon M. Nelaton to see a case of tetanus. Nelaton sat on 
the edge of the bed, watched the undressing of the wound, and withdrew 
without having touched the patient. A boy of eight years had been run 
over by a fiacre and brought to the hospital, having multiple contused wounds. 
Nelaton and the associate surgeon washed their hands in a solution of cor- 
rosive sublimate and partly dressed the wounds, an externe completing it. 
Seven days subsequently the boy began to exhibit unmistakable symptoms 
of tetanus, such as trismus, lockjaw, the sardonic grin, and opisthotonos, but 
eventually recovered (La France medicale, June 21, 1888). 

Dr. Adam reports the case of Chas. S- , who was admitted into the 

Foochow Native Hospital Sept. 28, 1887, with a crushed toe, which was am- 
putated, being gangrenous. On the following evening tetanus appeared. Case 

II. — S. I , aged thirty-one years, was admitted into the same hospital on 

Oct. 8th, having internal bleeding piles. These were ligated on the 10th, and 
the improvement was so rapid that he returned home, apparently well, on Oct. 
19th. On the following day he returned to the hospital, complaining of 
stiffness of the back and jaws. The disease was recognized. He became 
despondent, and died on the 26th. Tetanus not being common in Southern 
China, the occurrence of the above cases is strongly suggestive of the com- 
municability of the disease. Rochelot has also narrated (La Semaine med., 
Sept., 1888) two cases, the second of which evidently resulted from the first. 
They occurred in the laparotomy ward of a hospital, and, as the flower-beds 
of the hospital had recently been manured, it was believed that the first case 
originated from the infected soil. 

The fact familiar to army surgeons that after certain sanguinary battles 
the wounded who have fallen to the ground have been very liable to tetanus 
is most satisfactorily explained on the supposition that the soil of the battle- 
field contains the specific microbe. Sometimes tetanus follows injuries which 
are not attended by any breach of surface through which the bacillus could 
enter, and in some instances the intervals are so short between the injury and 
the commencement of the tetanus that it seems very improbable that the 
tetanus could be due to the agency of the bacilli, but rather to injury of the 
peripheral nerves, and consequent excitation of the reflex spinal system. 
Thus cases have been reported in which only twenty-four or twelve hours, or 
even a shorter time, elapsed between the injury and the tetanus — too short 
a time, it would seem, for the development of bacilli. In studying the causa- 



TETANUS NEONATORUM. 135 

tion of tetanus, whether of the neonati or of older patients, we should not 
overlook the fact that there is a form of the disease designated puerperal, of 
which form the late Sir James Y. Simpson collated the histories of over 
twenty cases. (See Simpson's Obstetrical and Gynecological Works, vol. i.) 
Puerperal tetanus occurs after abortion or labor at term, or after intra-uterine 
operations, and is probably correctly attributed to decaying animal tissue, 
which, excluded from oxygen, generates hydrogen and other poisonous gases. 
Such cases have given rise to the opinion held by some that the germs of 
tetanus are occasionally received into the system by inhalation, and are 
developed in the putrid substance with which they come in contact. Another 
theory held by some distinguished specialists in nervous diseases is that 
exposure to cold is an important cause, and is sufficient in itself to produce 
the disease. Hence Gower states that there is a variety of tetanus which is 
caused by exposure to cold, and which he designates idiopathic or rheumatic. 
By this theory it is easy to find an explanation for the origin of cases of 
tetanus neonatorum, several of which have been reported, in which the 
umbilicus and its vessels seemed normal and there was no injury of the 
cutaneous surface. In my opinion the time is not far distant when the 
bacillus of tetanus will be regarded as the cause of endemic, epidemic, and 
a large proportion of single cases. Occurring without traumatism or any 
appreciable cause, we may accept the theory of Gower, that in these cases of 
obscure origin the cause is " taking cold." But it seems to me not unlikely 
that the investigations in reference to the causation of tetanus may end in a 
similar way to those in regard to diphtheria ; that is, that true tetanus is 
always produced by the bacillus of Nicolaier, but there is a spastic muscular 
contraction in infancy as well as in adults which is due to a cause or causes 
distinct from the bacillus. 

In examining the literature of tetanus it is evident that the tonic con- 
traction of the muscles in certain cases which has been supposed to indicate 
the presence of tetanus has been due to spinal or cerebro-spinal meningitis, 
and not to tetanus. Thus, Billard reported a case in which tonic contraction 
of the muscles occurred in an infant three days old, and the anatomical 
characters observed after death were those of spinal meningitis. That tonic 
muscular contractions frequently occur in infancy and childhood in conse- 
quence of meningeal inflammation is well known, and in some of the epi- 
demics reported as tetanus meningitis was present, and was doubtless the 
cause of the muscular contractions. Such an epidemic was observed by Prof. 
Cederschjold in Stockholm in 1834. Within a few months he treated forty- 
two cases, and in the bodies examined after death he found a fibrinous exuda- 
tion at the base of the brain. I see no reason to doubt that the epidemic, 
which he describes as one of tetanus, was one of cerebro-spinal fever, more 
frequently designated cerebro-spinal meningitis. 

Time of Commencement in Fatal Cases. 

€ase 1. Male ; taken when three days old ; lived sixty hours. Labatt, Edin, Med. 

and Surg. Journ., April, 1819. 
" 2. Female ; taken when three days old ; lived forty hours. Ibid. 
" 3. Taken when five days old ; lived fifty hours. Ibid. 
" 4. Taken when three days old ; lived one day. Ibid. 
" 5. Male ; taken when two days old ; lived two days. Billard, Treatise on 

Diseases of Children, Stewart's trans., p. 477. 
" 6. Male ; taken when three days old ; lived two days. Romberg. 
il 7. Male ; taken when six days old ; lived ninety-three hours. Dr. Imlach, 

Month. Journ. of Med. Sci., Aug., 1850. 
" 8. Female; taken at five days ; lived four days. Caleb Woodworth, M. D., 

Boston Med. and Surg. Journ., Dec. 13, 1831. 



136 DISEASES OF THE NEWLY-BORN. 

Case 9. Negro; taken at seven days ; lived twenty-four hours. P. C. Gaillard, M. 
D., South. Journ. of Med. and Phar., Sept., 1846. 

" 10. Male ; taken when seven days old ; lived one day. Augustus Eberle, 
M. D., Missouri Med. and Surg. Journ.. 1847. 

" 11. Taken when seven days old. D. B. Nailer, N. 0. Med. Journ., Nov., 1846. 

" 12. Male; taken when three days old; lived one day. N. 0. Med. and Surg. 
Journ., May, 1853. 

" 13. Negro; taken when three days old; lived three days. Robert H. Chinn, 
M. D., N. O. Med. and Surg. Journ. 

" 14. Taken when two days old ; died in four hours after the doctor's visit. 
Ibid. 

" 15. Taken when seven days old ; lived one day. C. H. Cleveland, New Jersey 
Med. Rep., April, 1852. 

" 16. Negro ; taken when seven days old ; death finally. Greenville Dowell, 
Amer. Journ. of Med. Sci., Jan., 1863. 

" 17. Taken when twelve days old; lived one day. Thomas C. Boswell, com- 
municated to Dr. Sims. Amer. Journ. of Med. Sci., 1846. 

" 18. Taken when about five days old; died at about the age of nine days. B. 
R. Jones, Ibid. 

" 19. Taken at or soon after birth ; lived two days. Dr. Sims, Amer. Journ. of 
Med. Set, April, 1846. 

t; 20. Taken at the age of six days ; lived one day. Ibid. 

" 21. Taken when two days old ; lived two days. Ibid. 

11 22. Male ; taken at the age of eight days ; died in three hours. Communi- 
cated to the writer. 

" 23. Taken at the age of twelve hours ; lived two days. Communicated to the 
writer. 

" 24. Female ; taken when seven days old ; lived forty-five hours. The writer. 

" 25. Male taken at the age of seven days ; lived forty-eight hours. Ibid. 

" 26. Female ; taken at the age of eight days ; lived three days. Ibid. 

" 27. Female ; taken at the age of five days ; lived three days. Ibid. 

" 28. Female ; taken when four days old ; lived two days. Ibid. 

" 29. Taken when six days old; died next day. Ibid. 

" 30. Taken when five days old ; lived twenty-four hours. Ibid. 

11 31. Taken when eight days old ; lived two days. Ibid. 

" 32. Male : taken when five days old ; lived one day. Ibid. 

Favorable Cases. 

Case 1. Negro female ; taken when three days old ; recovered in a few days. Robert 
S. Baily, Charleston Med. Journ. and Rev., Nov., 1848. 

2. Negro ; taken at eleven days ; recovered in fifteen days. W. B. Lindsay, 
N. 0. Med, Journ,, Sept., 1846. 

3. Negro ; taken when ten days old ; recovered in thirty-one days. P. C. 
Gaillard, Charleston Med, Journ. and Rev., Nov., 1853. 

4. Male ; taken at the age of eight days ; recovered in twenty-eight days. 
Ibid. 

5. Negro ; taken at seven days ; recovered in fifteen days. Augustus Eberle, 
Missouri Med. and Surg. Journ., 1847. 

6. Taken when eight days old ; recovered in four weeks. Furlonge, Edin. 
Med. and Surg. Journ., Jan., 1830. 

7. Taken at the age of one week ; recovered in two days. Dr. Sims, Amer. 
Journ. of Med. Sci., April, 1846. 

8. Female ; taken at the age of three days ; recovered in five weeks. The 
writer. 

Period of Commencement. — Finckh, 1 who saw cases of tetanus of the 
newly-born in the Stuttgart Hospital, states that it began in 1 case on the 
second day after birth, in 8 on the fifth, and in 7 on the seventh. 

Copland 2 says that it generally commences on the first seven or nine days 

1 Hecker's Annalen, vol. iii. No. 3, p. 304. 2 Medical Dictionary. 






TETANUS NEONATORUM. 137 

after birth, and rarely later than the fourteenth. Romberg states that it 
commences between the fifth and ninth days. In 200 cases observed by 
Reicke in Stuttgart in the course of forty-two years it was never found to 
commence before the fifth, rarely after the ninth, and never after the eleventh, 
day. Schneider says that the disease occurs oftenest between the second and 
seventh, and rarely after the ninth, day. In 6 cases reported by Dr. C. Levy 
of Copenhagen it began in 2 on the third day, in 2 on the fifth, and in 2 on 
the sixth. Dr. Greenville Dowell, 1 who has seen much of tetanus neonatorum 
among the negroes in Mississippi and Texas, says it is almost sure to come on 
between the fifth and twelfth days after birth. In the 40 cases embraced in 
the above table the disease began as follows : 

Age. Cases. 

Under two days 2 

Two davs . 1 

Three days 9 

Four days 2 

Five days 6 

Six days 3 

Seven davs 8 

Eight days 6 

Ten days 1 

Eleven days 1 

Twelve days 1 

Pathology. — It is an interesting fact that in the warm regions of the 
United States the victims are chiefly negro infants. L. S. Grier, M. D., 2 of 
Mississippi says : " The first form of disease which assails the negro among 
us is trismus. The mortality from this disease alone is very great. No sta- 
tistical record, we suppose, has ever been attempted, but from our individual 
experience we are almost willing to affirm that it decimates the African race 
upon our plantations within the first week of independent existence. We 
have known more than one instance in which, of the births for one year, one- 
half became the victims of this disease, and that, too, in spite of the utmost 
watchfulness and care on the part of both planter and physician. Other 
places are more fortunate, but all suffer more or less ; and the planter who 
escapes a year without having to record a case of trismus nascentium may 
congratulate himself on being more favored than his neighbors, and prepare 
himself for his own allotment, which is surely and speedily to arrive." Dr. 
Wooten 3 says: " It is a disease of fatal frequency on the cotton plantations 
in this section of Alabama." He has, however, never seen a white child 
affected with it. 

While tetanus infantum prevails in regions wide apart and presenting 
very diverse climatic conditions, there is a similarity as regards the personal 
and domiciliary habits of the people who suffer most from its occurrence. It 
occurs chiefly among those who are filthy and degraded in their habits — who 
live, either from choice or necessity, in neglect of sanitary requirements. 
It is now demonstrated beyond all doubt that the bacillus of tetanus, like 
most pathogenic germs, is fostered and rendered more virulent by filth, and 
especially the soil which has been occupied by old stables and saturated by 
the excreta of horses, is the richest of all in the development of this microbe. 

That uncleanliness and impure air are causes of tetanus is as fully 
demonstrated as most facts in the etiology of diseases. The attention of the 
profession was forcibly directed to this cause by Dr. Joseph Clarke in a paper 

* Amer. Journ. of Med. Sri., Jan., 1863. 
2 iV. 0. Med. and Surg. Journ., Max, 1854 
3 Ibid., May, 1846. 



138 DISEASES OF THE NEWLY-BORN. 

read before the Koyal Irish Academy in 1789. This physician was in charge 
of the Dublin Lying-in Asylum, and had rightly concluded that the mortality 
among the new-born infants was due to imperfect ventilation. Through his 
advice, apertures (twenty-four inches by six) were made in the ceiling of each 
ward ; three holes, an inch in diameter, were bored in each window-frame ; 
the upper parts of the doors leading into the gallery were also perforated 
with sixteen one-inch apertures, and the number of beds was reduced. The 
results of these simple sanitary regulations may be seen from Dr. Clarke's 
own statement. He says : " At the conclusion of the year 1782, of 17,650 
infants born alive in the Lying-in Hospital of this city, 2944 had died within 
the first fortnight — that is, nearly every sixth child." The disease in nine- 
teen cases out of twenty was tetanus. After the wards were better ventilated 
— namely, from 1782 till the time of the preparation of Dr. Clarke's paper — 
8033 children were born in the hospital, and only 419 in all had died, or 
about one in nineteen. So impressed was Dr. Evory Kennedy, who at a 
later period had charge of the same asylum, with the belief that Dr. Clarke 
had discovered the true cause, and had been able in great measure to prevent 
it, that he enthusiastically writes : " If we except Dr. Jenner, I know of no 
physician who has so far benefited his species, making the actual calculation 
of human life saved, the criterion of his improvements." The cases occur- 
ring in my own practice have almost all been in tenement-houses, where 
habits of cleanliness are not observed, and I have not yet seen in the prac- 
tice of others nor heard of a case which occurred in the better class of dom- 
iciles. The statements of physicians in the Southern States, who speak from 
extensive observation among negroes, are strongly corroborative of the belief 
that the disease is in great measure due to uncleanliness and lack of pure air. 

Dr. Greenville Dowell of Texas states that he has been able to trace tetanus 
infantum to the bed-clothes, saturated with excrementitious matters, which 
are found in the negro cabins. In a paper published by Prof. John M. Wat- 
son 1 the frequency of this disease among negroes is accounted for as follows : 
" When called to see their children we find their clothes wet around their hips, 
and often up to their armpits, with urine The child is thus pre- 
sented to us, when, on examination, we find the umbilical dressings not only 
wet with urine, but soiled, likewise, with faeces, freely giving off an offensive 
urinous and fecal odor, combined at times with a gangrenous fetor arising 
from the decomposition, not desiccation, of the cord." 

In the bodies of the new-born who die of tetanus lesions are observed 
which doubtless result from the spasms. Again, others are found which from 
their nature could not be a result, and which, being observed in different 
cases, are believed to have a causal relation. The most frequent of such 
lesions is inflammation of the umbilicus or umbilical vessels. 

Moschion, who lived in the first century of the Christian era, stated, in 
writings still extant, that stagnant blood in the umbilical vessels sometimes 
is associated with dangerous disease in the new-born infant, and it is supposed, 
though this is doubtful, that he referred to tetanus. In modern times the 
attention of the profession has been more particularly directed to tetanus 
neonatorum by a paper published by Dr. Colles. 2 The observations contained 
in this paper were made in the Dublin Lying-in Hospital during a period of 
five years. In each of these years he witnessed from three to five post-mor- 
tem examinations in cases of infantile tetanus, and the lesions, he states, were 
in all much alike, as follows : The floor of the umbilical fossa was lined by a 
membrane apparently formed by suppurative inflammation, and in the centre 
of this fossa was a large papilla. This papilla consisted of a soft yellow sub- 

1 Nashville Journ. of Med. and Surg., June, 1851. 

2 Dublin Hospital Reports, vol. i., 1818. 



TETANUS NEONATORUM. 139 

stance, apparently the product of inflammation, and in all the cases the um- 
bilical vessels were in contact with this substance and were pervious. In a 
few instances superficial ulcerations were found near the mouth of the umbili- 
cal vein, and occasionally the skin surrounding the umbilicus was raised. The 
peritoneum covering the vein was highly vascular, often not to a greater dis- 
tance than an inch above the umbilicus, but sometimes as far as the fissure 
of the liver. The peritoneum in the course of the umbilical arteries pre- 
sented the inflammatory appearance in still greater degree, sometimes as far 
as the bladder. The connective tissue lying along the arteries and urachus 
anteriorly was loaded with a yellow watery fluid. The inner surface of the 
umbilical vein was not inflamed, but its coats in general were thickened. On 
slitting open the arteries a thick yellow fluid, resembling coagulable lymph, 
was found within their coats, and in all cases these vessels were thickened 
and hardened as far as the fundus of the bladder. 

Dr. Finckh, who observed 25 cases in the Stuttgart Hospital, believes that 
the most frequent pathological state was suppuration or ulceration of the 
umbilical cord. In 10 of the 25 cases the navel was dry and cicatrized; in 
the remainder it was either wet or swollen, with a bluish-red inflamed edge at 
the margin of the navel ; a dirty viscid pus covered the umbilical depression. 

Dr. Levy, physician at the Foundling Hospital in Copenhagen, attended 
22 cases in that institution in 1838 and 1839. Of these 20 died, and 15 were 
examined carefully after death. In 14 there were decided marks of inflam- 
mation of the umbilical arteries, especially of those portions lying along the 
urinary bladder ; in several cases the peritoneum over the arteries was much 
injected, and in 3 adherent either to the omentum or intestine by coagulable 
lymph ; the coats of the arteries were thickened, their cavities dilated and con- 
taining dark reddish-brown or greenish puriform matter, always fetid. Some- 
times the arterial tunica interna was found ulcerated and absent in places, and 
there was spongy thickening of the subjacent connective tissue. In 2 cases 
the ulcerative process had extended from the tunica interna to the peritoneum, 
and there was a deposit of thick ichorous matter around the ulcer ; in 1 case 
both arteries were so softened that their coats were scarcely distinguishable, 
and in another these vessels had become gangrenous. The appearance of the 
umbilicus was unchanged in 4 cases ; in 10 the fundus was red and filled with 
puriform fluid, which quickly reappeared when removed, and, in general, 
shortly before death the navel presented a greenish color. 

According to Romberg, Dr. Scholler made post-mortem examinations in 
18 cases of tetanus infantum, and in 15 found inflammation of the umbilical 
arteries. The vessels were swollen near the bladder, in 1 case to the diameter 
of four lines, and were found to contain pus. The lining membrane was eroded 
or covered with an albuminous exudation. Both arteries were not always 
equally inflamed, and in 3 cases only 1 was affected. 

Schneeman 1 found minute points of suppuration in the umbilical vein in 
8 cases, and pus throughout the course of this vessel in 1. 

The observations mentioned above were made, for the most part, in hos- 
pitals on the Continent, but similar observations have been made in private 
practice. M. Borian 2 of the Isle of Bourbon says that he has found in every 
case inflammation around the umbilicus. Dr. Ransom 3 states in a communi- 
cation to Prof. John M. Watson that he has never seen a case of tetanus of the 
new-born in which the umbilicus was healthy. In a case related by Robert 
S. Bailey* there was a hard scab on one side of the umbilicus, and this part 

1 Holscher's Annalen, vol. v. p. 484, 1840. 

2 Gazette medimle, Paris, July 11, 1841. 

3 Nashville Journ. of Med. and Surg., June, 1851. 

4 Charleston Med. Journ. and Rev.. Nov., 184S. 



140 DISEASES OF THE NEWLY-BORN. 

was much distended. A discharge followed the removal of the scab, and the 
child recovered. In a favorable case related by W. B. Lindsay l the umbilicus 
was tumid and not disposed to heal. Dr. H. 0. "Wooten 2 attributes the disease 
to the condition of the umbilicus and umbilical vessels, and states that he has 
found the umbilicus gangrenous. A case has been reported in which the 
umbilical vessels were blocked up by purulent matter. 3 At a meeting of the 
Obstetrical Society of Edinburgh, held April 24, 1850, Dr. Imlach related a 
case in which there was a dark and gangrenous appearance on the integument 
around the umbilicus, and the peritoneum underneath was also dark, but not 
inflamed ; umbilical vein healthy ; a little fibrin in the left umbilical artery ; 
right umbilical artery much diseased ; its two inner coats apparently destroyed, 
and in their place a yellow pultaceous slough in which pus-globules were dis- 
covered with the microscope. 

It is evident that the pathological state of the umbilicus and umbilical 
vessels described above, which has been noticed by so many observers in 
different countries, cannot result from the tetanus. It is possible that the 
puriform substance noticed in the umbilical vessels was disintegrated fibrin, 
which had coagulated at the time of ligation of the cord, and the cells seen 
by Dr. Imlach and others may sometimes have been white corpuscles still 
remaining from the stagnated blood. 4 Still, the evidences of inflammation, 
in at least a part of the cases related above, were of a positive character. 

The belief that umbilical lesions occasionally cause tetanus infantum com- 
ports with the well-known traumatic causation of tetanus in the adult. This 
belief is strengthened by the fact which will appear farther on in our remarks 
that tetanus of the new-born, from being frequent in certain localities, has 
become infrequent through greater care in dressing and managing the umbili- 
cal cord. 

But there are cases of tetanus infantum in which there is no disease in 
or about the umbilicus. Dr. Finckh of Stuttgart examined the umbilical 
vessels in eleven cases without discovering any pathological change. Dr. 
Samuel B. Labatt, 5 master of the Dublin Lying-in Hospital, published a 
paper entitled " An Inquiry into the Alleged Connection between Trismus 
Nascentium and Certain Diseased Appearances in the Umbilicus." This 
paper was designed as a reply to the essay of Dr. Colles. Dr. Labatt relates 
several cases in which there was no disease of the umbilicus and umbilical 
vessels, and others in which the disease was so slight that it probably pro- 
duced no injurious effect on the health of the child. Dr. James Thompson, 6 
who spent considerable time in the tropical regions, says : " I have myself 
examined nearly 40 cases of infants that have sunk under this complaint. 
In many I have looked at no other part than the navel, and have found it 
in all states — sometimes perfectly healed, especially if the infants had 
lived several days ; at other times a simple clean wound. When death 
occurred on the fifth or sixth day the wound was frequently in a raw state. 
I never yet saw it in a sphacelated condition." The writer concludes from his 
observations that there are cases in which the cause is located elsewhere than 
in the umbilicus or umbilical vessels. Dr. John Breen 7 remarks: "From 
dissections .... we have never been able to discover any peculiar morbid 
appearance which would justify us in offering any explanation of the pathol- 
ogy of the disease." In my own cases there was no evidence of disease of 
the umbilicus or umbilical vessels, so far as could be ascertained by external 

1 N. 0. Med. and Surg. Journ., Sept., 1846. 2 Ibid., Mav, 1846. 

3 Ibid., May 1, 1853. * VirchonJ s Cellul. Pathol. 

6 Edin. Med. and Surg. Journ., April, 1819. 6 Ibid., Jan., 1822. 

7 Bub. Journ. of Med. and Chem. Sci., January, 1836. 



TETANUS NEONATORUM. 141 

examination, and in one (No. 32) a careful post-mortem examination dis- 
closed no lesion of these parts. 

Other observations might be related showing that the bacillus of tetanus 
does in most instances enter the system of the newly-born through the 
umbilicus and umbilical vessels, but a lacerated or wounded surface may be 
the gateway of infection whatever the age. 

Symptoms. — In many cases premonitory symptoms are absent or are so 
slight as to escape notice. In some patients fretfulness precedes the attack, 
but no more than is often observed in those who continue in good health. 
The first symptom which alarms the parents and shows the grave nature of 
the commencing disease is inability to nurse or evident pain and hesitation in 
nursing. Commencing with rigidity of the masseters, the disease gradually 
extends to the other voluntary muscles, and in the course of a few hours the 
muscles of the limbs as well as of the trunk are involved. Persistent mus- 
cular contraction, which is the pathognomonic feature of infantile tetanus, is 
developed not fully in the beginning, but by degrees in each aiFected muscle, 
so that it is not till after the lapse of several hours, perhaps even a day, that 
the greatest amount of rigidity is attained. Therefore in the commence- 
ment of the disease the limbs can be flexed and the jaw pressed open 
more readily than at a subsequent stage, though with manifest pain to the 
infant. 

During the period of maximum rigidity the jaws are fixed almost immov- 
ably, often with a little interspace between them, against which the tongue 
presses and in which frothy saliva collects. The head is thrown backward 
and held in a fixed position by the stiffness of the cervical muscles. The fore- 
arms are flexed ; the thumbs are thrown across the palms of the hands, and 
are firmly clenched by the fingers ; the thighs are drawn toward the trunk ; 
the great toes are adducted and the other toes flexed. Occasionally opisthot- 
onos results from the extreme contraction of the dorsal and posterior cervical 
muscles. The infant can sometimes be raised without any yielding of the 
muscles by the one hand under the occiput and the other under the heels. 

The rigidity is liable to variation in its intensity even after the full devel- 
opment of the disease. If the infant be quiet, especially if asleep, the mus- 
cles are partially relaxed to such an extent sometimes, in the first stages of 
the complaint, that the features have a placid and natural expression, though 
only for a short time. Frequent exacerbations occur in the muscular con- 
traction, sometimes without any apparent cause, and sometimes produced 
by anything which excites or disturbs the child. Attempts to open the 
lips or jaws or eyelids or to bend the limbs, blowing on the face, and even 
the crawling of a fly upon it, occasion the paroxysms. 

During the paroxysm the eyelids are forcibly compressed, as well as the 
lips, which are either drawn in or are pouting ; the forehead and cheeks are 
thrown into wrinkles and the physiognomy is indicative of great suffering. 
The unnatural positions of the trunk and limbs which result from muscular 
contraction are increased for the moment ; the head is more forcibly thrown 
back and the limbs more strongly flexed. The muscular movements which 
occur during the paroxysms are sometimes described as clonic spasms. There 
is indeed occasionally some quivering of the limbs, and yet. as I have on differ- 
ent occasions noticed, so far from the muscular action being a clonic spasm, 
it is clearly tonic and is intensified during the paroxysm. In fatal cases the 
paroxysms occur more and more frequently until the period of collapse. 

The crying of the child affected by tetanus is never loud, however great 
the suffering. It is variously described by writers as " whimpering " or 
" whining." It is of this suppressed character in consequence of the rigid 
state of the respiratory muscles and their imperfect movement. 



142 DISEASES OF THE NEWLY-BORN. 

During the exacerbation respiration is suspended, or so imperfect and the 
circulation so retarded that the surface becomes of a deep-red, almost livid, 
color. Sometimes epistaxis occurs, affording partial relief to the congestion, 
and sometimes, though less frequently, the blood forces itself from the con- 
gested liver along the umbilical vein and escapes from the umbilicus. The 
intense passive congestion consequent on the tetanic spasm is general through- 
out the system, but extravasation of blood appears to be more common around 
the brain and spinal cord than elsewhere. 

The frequency of the pulse and respiration varies in different cases and 
at different stages of the same case. They are often somewhat accelerated, 
but at other times are natural, or are even slower than in health. 

While the appetite of the infant, to appearance, is not diminished, the 
pain which it experiences in nursing is such that alimentation is necessarily 
deficient. It can be fed with a spoon for a time after it ceases to take food 
in the natural way, but artificial feeding soon fails. The milk placed in its 
mouth is in great part pressed back through the violence of the spasm which 
is induced by the attempt to feed it. 

In consequence of imperfect nutrition the infant rapidly wastes away. 
There is no other disease, except the diarrhoea! affections, in which the ema- 
ciation is so rapid. In a case related by Dr. W. B. Lindsay l the record states 
that " the infant was fat three days before, but was now emaciated." Rom- 
berg, who saw tetanus neonatorum in European hospitals, and Robert H. 
Chinn 2 of Texas, both speak of the rapid emaciation. The trunk and extrem- 
ities lose their fulness and the features become pinched. Several observers 
have noticed the appearance of miliaria in this reduced state of system, 
especially around the shoulders, and sometimes a decidedly icteric hue 
appears on the skin. 

The condition of the intestines is not uniform. They may be relaxed, 
particularly if the disease be due to some irritation in them ; in other cases 
the stools are natural or constipated. 

It is often difficult to ascertain the state of the eyes, since attempts to 
open the eyelids bring on spasms and cause firm compression of the lids 
against each' other. According to Sir Henry Holland, one of the first symp- 
toms which occurred in cases on the island of Heimacy was strabismus, with 
rolling of the eyes. But this statement must be received with caution, since 
these cases were not seen by any physician and the information was obtained 
from the parents and priests. If true, the proximate cause of the disease in 
Heimacy would seem to be located in the cerebro-spinal axis. Contraction 
of the pupils commonly occurs in the stage of collapse. 

Mode of Death. — Death in infantile tetanus may occur from apnoea in 
the paroxysms, from extreme congestion of the cerebral vessels, or apoplexy ; 
and, lastly, it may occur from exhaustion. The last mode is probably the 
most frequent. 

Prognosis. — All writers till recently agree that tetanus of the infant 
rarely terminates favorably. Cullen attributes the ignorance of physicians 
in regard to this disease to the fact that it is so little amenable to treatment 
that they are not usually summoned to attend those affected with it. In the 
island of Heimacy, of 185 cases occurring during a series of years about the 
commencement of the present century, not one survived; and in the same 
locality, at Westmannoe, a small islet, 64 per cent, of all the infants born 
died of trismus (report of Dr. Schleisner). Similar statements in regard to 
the mortality of tetanus infantum are given by physicians in the Southern 
States. Dr. H. 0. Wooten 3 of Alabama says that he has " never seen a 

X N. 0. Med. Journ., Sept., 1846. 2 iV. 0. Med. and Surg. Journ., Sept., 1854. 

3 N. O. Med. Journ., May, 1846. 



TETANUS NEONATORUM. 143 

decided case of tetanus nascentiurn that did not prove fatal, .... and that 
it is very generally deemed useless to call in medical aid after the initiatory 
symptoms are well declared." Mr. Maxwell, 1 speaking in reference to the 
West Indies, says : ; ' From observations which I have made for a series of 
years, .... I found that the depopulating influence of trismus nascentium 
was not less than 25 per cent. It scarcely has a parallel within the bills of 
mortality." Dr. D. B. Nailer 2 says : ki About two-thirds of the deaths among 
the negro children are from this disease, and so uniformly fatal is it that a 
physician is never sent for." 

Yet death does not always result : eight of the forty cases in my collection 
recovered ; but a correct opinion cannot be formed from this of the actual 
ratio of favorable to unfavorable cases, since favorable cases are much more 
likely to be published. In the history of these 8 cases two interesting facts 
are noticed, which when present may serve as a ground for hope of a success- 
ful termination. These were, the age at which the disease began and the 
fluctuations of the symptoms. With two exceptions, the infants who recov- 
ered were about a week old when the initiatory symptoms appeared, and there 
were fluctuations in the gravity of the symptoms ; whereas fatal cases ordi- 
narily grow progressively worse. Yet in favorable cases the symptoms are 
never so severe as they become in a Jew hours in those who succumb. 

Duration in Fatal Cases. — Of 18 cases observed by Finckh in the 
Stuttgart Hospital, 15 died in two days, 2 in five days, and 1 in seven days. 
During the epidemic in the Stockholm hospitals in 1834, where 42 cases were 
treated, the disease seldom lasted more than two days. Romberg says : " It 
generally lasts from two to four days, but its duration is at times limited at 
from eight to twenty-four hours, and occasionally, though rarely, it extends 
from five to nine days." 

In 31 fatal cases in my collection, in which the duration is mentioned, 

1 lived 3 hours. 

11 others lived 1 day or less. 

12 lived 2 days. 

4 lived 3 " 

3 lived 4 " 

Both Underwood, who published a treatise on diseases of children in 
1789, and Dr. Elsasser at a more recent date, recorded fatal cases which were 
unusually protracted. The one described by Underwood was treated in the 
British Lying-in Hospital, and, although all the others treated in this institu- 
tion died by the third day, this lived six weeks ; but it is suggested by the 
author that death was due in part to some other affection. The child treated 
by Elsasser lived thirty-one days. 

Duration in Favorable Cases. — In the 8 favorable cases in my col- 
lection the duration of the disease, reckoned from the time when the infant 
ceased nursing till it began again, was as follows: In 1 case, two days; in 
1, a few days; in 1, fourteen days; in 2, fifteen days; in 1, twenty-eight 
days ; in 1, twenty-one days ; and in the remaining case, about five weeks. 

Diagnosis. — To one who has seen this disease in the new-born or is 
familiar with its symptoms diagnosis is easy. The symptoms which possess 
diagnostic value are more manifest and reliable than in most other infantile 
maladies. Permanent rigidity of the voluntary muscles, with temporary 
exacerbations, such as have been described above, which are induced by any 
cause which disturbs the infant, as attempts to open the mouth or eyelids, is 
pathognomonic. 

1 Jamaica Phys. Journ., copied into the London Lancet, April 11, 1S35. 
2 N. 0. Med, Journ., November, 1846. 



144 DISEASES OF THE NEWLY-BORN. 

Let us stop for a moment and consider the facts related above which have 
a bearing on therapeutics : 

(1) With possibly a few exceptions tetanus, whether occurring in man 
or animals, whether in the infant or adult, is the same disease, and is caused 
by the entrance into the system of a rod-shaped microbe two or three times 
the length of the tubercular bacillus. One end of the bacillus is somewhat 
rounded, so as to give it a pin-shape, and is enlarged by the presence of a 
spore. 

(2) The tetanus bacillus, as stated above, thrives most luxuriantly, and 
probably is most virulent, where dirt and filth abound. We have said also 
that its natural home is the soil, and not so much the virgin soil as soil 
which is rendered impure by the proximity and drainage of barnyards, and 
especially horse-stables. 

(3) Of the domestic animals, the horse and, to a less degree the sheep, are 
liable to tetanus, and hence those who are exposed by their occupations to 
these animals or to the soil infected by their excretions are more liable to 
tetanus from injuries, even from slight bruises or wounds, than are those 
whose occupations do not bring them into constant contact with these animals 
or with infected soil. 

(4) We have stated that the bacillus of tetanus is widespread, so that 
this disease occurs in every climate from the Arctic regions to Demerara or 
Bombay. But this bacillus, like that of diphtheria, has remarkable vitality 
and power for propagation, so that it has continued for an indefinite time to 
survive and multiply in certain localities, as in parts of Long Island, not- 
withstanding constant tillage. 

(5) As regards tetanus neonatorum, the observations which I have related 
show beyond doubt that in most instances the specific bacillus obtains entrance 
into the system through the umbilical blood-vessels and lymphatics, and 
within these vessels the toxine described and analyzed by Brieger and others, 
and which is so fatal, is produced. 

Preventive Treatment. — While tetanus neonatorum, if fully developed, 
is ordinarily fatal in spite of any remedial measures heretofore used, there is 
no doubt of the efficacy and value of preventive measures when properly 
employed. This was shown by the great reduction in mortality in the Dub- 
lin Lying-in Hospital through the thorough ventilation introduced by Dr. 
Clarke. Dr. Meriwether 1 of Montgomery, Ala., says: "When the disease 
appears endemically on a plantation it may be arrested by having the negro 
houses whitewashed with lime inside and out ; by raising the floors above the 
ground ; by removing all filth from under and about the houses ; by par- 
ticular attention to cleanliness in the bedding and clothing of the mother 
and in the dressing of the child, so as to prevent any of the matter from the 
umbilicus lying long in contact with the skin." Many physicians, especially 
in the Southern States, speak confidently of care in dressing the cord and 
attention to the umbilicus as a means of prevention. Graften 2 says that he 
has " never known the disease to occur in any child whose navel had the tur- 
pentine dressing." He uses turpentine as follows : "At the first time a few 
drops of undiluted turpentine are applied immediately to the umbilicus around 
the cord, and it is anointed at every succeeding dressing, the turpentine being 
diluted one-half or two-thirds with olive oil, lard, or fresh butter." This use 
of turpentine has also been recommended by other practitioners in warm 
regions. 

Dr. John Furlonge 3 of St. John's, Antigua, believes that no case would 

1 Amer. Journ. of Med. Sci., April, 1854. 

2 N. 0. Med. and Surg. Journ., July, 1853. 

3 Edln. Med. and Surg. Journ., January, 1830. 



TETAXUS NEONATORUM. 145 

occur with the following treatment : " The cord, when divided, should be 
wrapped in clean linen. Every night for two weeks one or two drops of 
tinct. opii and spts. vini, equal parts, should be given, and castor oil, with a 
little magnesia, every morning. The child must be washed in tepid water 
every morning and the funis dressed." If this treatment be attended by the 
success which is claimed for it by Dr. Furlonge, so great care in dressing the 
cord is certainly well repaid in localities, as at Antigua, where a large pro- 
portion of the infants die of tetanus. But since it is now known that tetanus 
neonatorum, like that at a more advanced age, usually has a microbic origin, 
an antiseptic and germicide dressing of the cord is evidently preferable, as by 
filling the umbilicus and dusting the cord with aristol. 

Some experienced observers go so far as to assert that it is possible to 
ward off tetanus neonatorum after the occurrence of premonitory symptoms. 
Dr. Dowell l says : " Some with slight twitchings of the muscles have recov- 
ered without any trouble by being put into a mustard-bath, washed clean, and 
put in a clean and well-ventilated cabin." 

Treatment. — In considering the effect of medicinal agents which have 
been employed in the treatment of infantile tetanus, the great difficulty which 
the child experiences in swallowing should be borne in mind. Without care 
a considerable part of the dose is lost by the spasm of the muscles of degluti- 
tion, which ordinarily occurs when the spoon is placed in the mouth, so that, 
unless special attention be given to this matter, it is uncertain whether the 
prescribed dose is fully administered. 

The treatment employed by different physicians has been very diverse. 
Antiphlogistic remedies were prescribed by Finckh, but every case so treated 
was fatal. He states that whenever blood was abstracted, even in small quan- 
tities, the symptoms were aggravated. The same result has followed depletory 
measures in the practice of other physicians. 

The internal remedies which have been most frequently prescribed are 
opiates and antispasmodics. Furlonge in a favorable case gave laudanum in 
doses of one drop every three hours alternately with two grains of Dover's 
powder. Woodworth also gave one-drop doses of laudanum ; Eberle, one- 
sixth of a drop hourly. The opiate has generally been given in combination 
with an antispasmodic. The Dover's powder given every three hours by 
Furlonge was combined with five grains of sulphate of zinc. The hourly 
doses of laudanum by Eberle were combined with six drops of tincture of 
asafoetida. 

When anaesthetics began to be employed in the treatment of diseases it 
was believed that they would be especially useful in cases of tetanus. Accord- 
ingly, chloroform has been used in tetanus in the infant, with the effect of 
controlling the spasm during the time of its use, but without curing the dis- 
ease. In Case 7 in our first table it was employed several times, but appar- 
ently without delaying the fatal result. The editor of the New Orleans 
Medical and Surgical Journal states, in the May issue of that periodical for 
1853, that he has used chloroform in tetanus neonatorum, with the effect, he 
believes, of prolonging life. Anaesthetics certainly relieve the suffering of 
the infant, and on this account, even if they do not prolong life, their judi- 
cious employment seems proper. 

The remedy which has been more efficient than those mentioned above 
has been the hydrate of chloral, given with or without one of the bromides. 
Since the introduction of this agent into therapeutics it has been employed 
by several physicians in the treatment of this disease with so good a result 
that it will probably supersede all other medicines for this purpose. Dr. 
Widerhofer of Vienna states that he has saved six out of ten or twelve bv 
1 Amer. Journ. of the Med. Sci., January, 1863. 
10 



146 DISEASES OF THE NEWLY-BORN. 

the use of chloral. He prescribes it in doses of one to two grains by the 
mouth, or, if there be great difficulty in swallowing, two or four grains by 
the rectum. Dr. F. Auchenthales relates a case in which he gave even six- 
grain doses, and in nine days the disease had entirely disappeared. I have 
recently employed hydrate of chloral in a case of tetanus, giving it in half- 
grain or one-grain doses every two hours, except when there was profound 
sleep. The disease was fully developed and the symptoms severe when I was 
called. I did not believe that the infant with the old remedies would live 
more than two days, but by the use of chloral life was prolonged nearly one 
week. Moreover, by the use of chloral the suffering of the infant is greatly 
diminished. The frequent inhalation of sulphuric ether also aids materially 
in controlling the spasms. 

The administration of alcoholic stimulants is required at short intervals 
on account of the rapid emaciation and great prostration. 

Local treatment directed to the umbilicus in those cases in which there 
is evidence of inflammation of the umbilicus or umbilical vessels should not 
be neglected. The application of an emollient poultice to the umbilicus has 
been followed by apparent improvement, if we may believe the statement of 
some physicians who have made use of this treatment. Dr. Meriwether of 
Alabama says if there be no improvement from the medicine which he orders 
he applies a blister, larger than a dollar, to the umbilicus, and with this treat- 
ment the child generally improves — a remarkable statement since so few 
improve at all. 

No one can fail to observe the need of early and continuous antiseptic 
treatment of the umbilicus, as in septicaemia. Aristol, iodoform, boracic or 
salicylic acid should be constantly and as deeply applied in the umbilical 
fossa as possible, mixed with a liquid, perhaps glycerin, to make it penetrate 
more deeply. 

A warm foot-bath, repeated at intervals of a few hours, and stimulating 
embrocations along the spine, are proper adjuvants to the treatment. 

The apparent encouraging results of the treatment of diphtheria by the 
subcutaneous injection of the serum of an animal rendered immune to this 
disease by repeated inoculations led to observations and experimentation to 
determine whether a similar treatment might be useful in tetanus. We have 
seen how the bacillus of tetanus can be propagated and obtained in the flask 
of the chemist, and it is easily communicated to the horse by inoculation. 
Tizzoni and Cattani, followed by others, have employed the antitoxine treat- 
ment of tetanus. It is obviously best, in order to determine its efficiency, to 
learn the results of its use whatever the age, for it is the same disease in 
infancy, childhood, and adult life. 

Escherich reports ( Wien. Jdin.Woch., Aug. 10, 1893) four cases of tetanus neona- 
torum treated by Tizzoni's antitoxine. The following are the statistics of these cases : 
In the four cases the umbilical cord was detached on the sixth, third, fourth, and 
fourth days : the incubation was two, nine, one, and seven days ; the duration, two, 
five. two. and twelve days. The fourth or last case only recovered. In all who 
died septic inflammation of the umbilical cord was present, and all exhibited septic 
symptoms. A little of the tissue at the umbilicus, taken from the bodies of the first 
and third cases and inoculated in mice, caused tetanus in them. In Case 1 (fatal) 
only 0.015 by 2.0 of antitoxic serum was injected; in Case 2 (fatal) the injections 
of 0.25 were discontinued on account of the occurrence of septic pneumonia ; in 
Case 3 (fatal) the tetanus was exceptionally severe, so that a good result could not 
be expected. In the case that recovered an injection (0.3) was given on the third 
and twice on the fourth day. 

Lesi (Rif. Med., Aug. 18, 1893) : A man wounded his foot with a piece of glass 
while walking over a heap of stable manure. Six days later tetanic phenomena 
appeared, which rapidly involved the muscles of the legs, neck, and back, and 






TETANUS NEONATORUM. 147 

caused marked trismus and dysphagia. On the afternoon of the second day after 
the appearance of the symptoms the patient received a hypodermic injection of 50 
cc. of serum obtained from one of Tizzoni's immunized horses, 1 gramme of which 
serum had been found sufficient to protect 10,000,000 grammes. After this injec- 
tion there was no further spread of the tetanic symptoms, which remained confined 
to the parts already affected. In these parts, indeed, the spasms became somewhat 
more pronounced during the first and second days of treatment. During the even- 
ing of the second day a further injection of 20 cc. was given, after which the patient 
had a fair night's rest. The next day another injection of 10 cc. was given. The 
patient was almost free from pain, except for the trismus and difficulty in swallow- 
ing. On the fourth day a last injection of 20 cc. was given, after which the patient 
rapidly convalesced and was able to leave the bed six days after the admission. 

In the British Med. Jowm., January 19, 1895, the case of a man is related who 
was injured by a catapult, and six days afterward began to have tetanic symptoms. 
The wound was half an inch below the symphysis of the lower jaw, and gave rise 
to a foul discharge containing shreds of string and shoemaker's wax. Trismus, 
inability to open the mouth, prominence and rigidity of the muscles of the neck 
and back followed. The symptoms gradually increased, and on the third day of 
the tetanus 2.5 grammes of Tizzoni's antitoxine in sterilized distilled water were 
introduced by punctures in the abdominal walls. Each puncture was painful and 
was attended by strong opisthotonic spasms. On the following day, October 7, or 
fourth day of the tetanus, 1 gramme (15 grains) was injected. On each of the fol- 
lowing days. October 8, 9, 10, 11, 12, and 13, either one-half or one gramme (7J or 
15 grains) was injected, but none was used on the 15th. On October 16 his tongue 
was caught between the teeth, and could not be released by the attendants. Violent 
and almost continuous spasms followed, with laceration of the tongue and great 
dyspnoea. When the patient appeared to be dying, grain ^ of physostigmine and 
grain k of morphine were injected, and in less than a minute the masseters were so 
relaxed that the lacerated tongue was released and the lividity, dyspnoea and violent 
opisthotonic spasms ceased. On this eventful day the antitoxine was not employed, 
so that forty-eight hours elapsed without its use. On October 17th, 18th, and 19th 
one gramme each day was administered, and on October 20th half a gramme. From 
this time the patient steadily improved. 

Mr. Marriott, who reported the above case, summarizes the treatment as 
follows : •• Antitoxine, with the exception of the three injections of the phy- 
sostigmine and morphine, was the only remedy used in this case, as, though 
chloral was at first prescribed, only a very small quantity was swallowed. 
The patient certainly seemed much relieved by the treatment, and it is to be 
remarked that the severe and nearly fatal relapse occurred after the diminu- 
tion of the close on October 14th and its suspension on October 15th. He 
states also that the two injections of physostogmine and morphine when 
given together had a most salutary effect in diminishing the spasms." 

In the same number of the British Med. Journal a case is related better 
adapted to our purpose, for it is one of tetanus neonatorum treated with 
tetanus antitoxine, reported by Mr. Firth. The infant was born on Septem- 
ber 18, 1894, and after ligation of the cord the navel was dressed with a 
clean piece of linen. On the sixth day it was dressed with a scorched piece 
of linen soaked in castor oil. On the eighth day the infant was fretful and 
took the breast with difficulty. On the eleventh day after birth or fourth 
of the disease it was admitted into the Bristol General Hospital, and on the 
fifth day of the disease it was more carefully examined. It was icteric ; its 
eyelids tightly closed, the conjunctivae could not be seen ; the face was 
wrinkled; no risus sardonicus ; masseters hard; lower jaw rigidly fixed; 
head slightly retracted ; neck and spine very rigid ; arms and forearms 
adducted and rigid; fingers firmly flexed into the palm, and thumbs firmly 
flexed over them ; it swallowed with great difficulty, and became cyanotic 
when a little milk was placed in the mouth ; spasms, lasting three or four 
minutes and beginning and ending gradually occurred ; temperature normal 



148 DISEASES OF THE NEWLY-BORN. 

or slightly subnormal ; pulse 12.8, resp. 36 ; chloral hydrate gr. i and potas. 
bromide, gr. 1 to 2, were administered every four hours. 

On the sixth, seventh, and eighth days no improvement occurred, but 
spasms of tonic muscular contractions severe and attended by cessation of 
respiration and very frequent, weak, or inappreciable pulse were present. At 
one time it was thought to be dead. On the eighth day of the disease the 
tetanus antitoxine was employed, six grains being injected under the skin of 
the abdomen in five places. On the ninth day a similar injection was made 
at 4 p. m., and the third at 8.30 P. m. On the tenth day the patient had 
eight of the spasmodic attacks of muscular rigidity lasting from five to 
fifteen minutes, and the longest suspension of respiration in the attacks was 
seven minutes. A last injection of twelve grains of tetanus antitoxine was 
made at 1 p. m., and death occurred at 8 p. m. 

It will be seen that the infant had four injections of the antitoxine, two 
grammes or thirty grains in all, without any appreciable controlling effect on 
the tetanus. No post-mortem examination was allowed, and nothing in the 
external appearance indicated that the navel or umbilical vessels sustained 
any causal relation to the tetanus. 

From the above cases, and from others of a similar nature which have 
been published, it appears that the tetanus antitoxine in order to be efficient 
must be used early, and more observations are required in order to ascertain 
what power it possesses in the treatment of tetanus even at an early stage. 
The tetanus antitoxine, like that of diphtheria, is still on trial, and many more 
observations will be required before its efficiency is determined. With or with- 
out this new remedy it is evident that the hydrate of chloral, with perhaps 
one of the bromides, should still be employed. 

The method of preparing and using the antitoxic serum is as follows : 
The toxine employed for immunizing the horse is prepared in a flask contain- 
ing grape-sugar bouillon and hydrogen, in the manner described by Mr. Hew- 
lett, which I have already related. The toxine of tetanus prepared in this 
manner in the flask of the chemist is such a powerful poison that in employ- 
ing it to immunize the horse by subcutaneous injections it is first diluted by 
admixture with an equal quantity of Grain's iodine solution. Hewlett in 
immunizing the horse employed three injections weekly, beginning with .5 
c.cm., and gradually increasing to 8 c.cm. or 10 c.cm. from May 2d to June 
22d, after which Mr. Hewlett gradually diminished the diluent until the pure 
toxine was employed on and after July 2d, but sometimes with dangerous 
symptoms. " On July 25th, 4 c.cm. were injected into the jugular vein, fol- 
lowed by rather alarming symptoms half an hour after, the animal falling 
prostrate with legs extended, labored respiration, and rapid small pulse." 
The animal recovered in ten minutes. As in preparing the diphtheritic anti- 
toxine, the horse should receive these injections about three times weekly for 
three to six months, but before immunized serum is placed in the hands of 
the physician or pharmacist it should be tested upon animals. 

Mr. Hewlett writes in reference to the antitoxic serum of the horse prop- 
erly prepared as follows : " Experimentally, the effects of the antitoxine are 
little short of marvellous. Minute doses injected into animals will completely 
neutralize fatal doses of the tetanus toxine injected eight or twelve hours 
afterward. Thus, 0.0005 c.cm. of the antitoxic serum was found to be suffi- 
cient to protect a guinea-pig weighing 400 to 500 grammes from the minimum 
fatal dose of the tetanus toxine, which in the present instance was about 0.01 
c.cm. Mixtures of the toxine with the antitoxic serum in the proportion of 
forty or fifty parts of the former to one of the latter are completely inert, and 
2 cubic centimetres of such a mixture, containing nearly 2 c.cm. of the deadly 
toxine, may be injected into a guinea-pig without producing any effect. The 



SCLEREMA NEONATORUM. 149 

antitoxine also possesses considerable curative power, but much larger doses 
are necessary when the disease has declared itself than when used as an 
immunizing agent." 

•• The antitoxine treatment of tetanus would seem to be the one which gives 
the best hope of cure. ... I have been able to collect records of 42 cases 
of tetanus treated with antitoxine, nearly all traumatic, and of these 15 died 
and 27 recovered, giving a mortality of about 36 per cent. . . . The anti- 
toxine must be administered by subcutaneous injection. It is difficult to 
state what the dose should be, for this has varied enormously in recorded 
cases. — from 10 c.cm. to 165 c.cm. Probably 20 c.cm. to 40 c.cm for the 
first dose, followed by 10 c.cm. every six to twelve hours, would be found 
most suitable.' 1 

Sclerema Neonatorum. 

This is a rare disease, and most of the cases which have been observed 
have occurred in foundling asylums or maternity wards. It is characterized 
by induration of the skin and subcutaneous tissue over a greater or less 
extent of the system. The sensation communicated to the finger pressed 
upon the affected surface is not unlike that produced by the cadaver. Those 
having the disease are feeble, poorly nourished, and a considerable proportion 
are prematurely born. Their temperature is below normal. 

Sclerema of the newly-born was first described by Underwood in the 
eighteenth century, and following him, in 1781, Andry applied this term to 
oedema occurring in the first days after birth, and which should not be con- 
founded with sclerema. Sclerema neonatorum occurs in emaciated or atrophic 
infants, but the skin over the affected part, instead of lying in wrinkles 
or folds, as is usual in a state of great emaciation or atrophy, becomes 
smooth and is firmly adherent to the subjacent parts, from which it cannot 
be raised. The induration usually first appears in the lower extremities, and 
it passes upward along the hips and lumbar region, and it may occur not only 
upon the trunk and upper extremities, but even upon the face. The limbs 
are extended and immobile, and the soft parts, firm and resisting, do not pit 
on pressure. The skin has a dusky-yellow color and is perhaps slightly 
cyanotic. The respiration is feeble and slow. The rigidity when extensive 
resembles that in tetanus. Nursing from the breast is imperfectly performed, 
and when the muscles of the face and lips are involved is impossible. The 
causes of sclerema appear to be prematurity, atrophy or poor nutrition, and 
great heart failure. 

This disease, so long as the patient is able to take nutriment, may con- 
tinue for weeks before the fatal ending, with a constant abnormally low tem- 
perature. 

Parrot made post-mortem examinations, and found hardening and atrophy 
of the skin and rete Malpighii, the cells pertaining to which being indistinct 
and forming a firm mass. In the adipose tissue underlying the skin the fat 
had disappeared to a considerable degree, the fat-cells being atrophied, but 
having distinct nuclei. The fibres of the connective tissue were apparently 
increased in number and thickness. The blood-vessels, particularly in the 
papillae, were shrunken or narrowed to such an extent that their lumina were 
not visible. Henoch made a post-mortem examination of the brain and spi- 
nal cord in two cases which had lain for weeks in his ward in a rigid state. 
and found them normal. 

A clear idea of the symptoms and anatomical characters of sclerema can 
be obtained by the narration of a typical case that occurred in the New York 
Foundling Asylum. The curator gave a full and graphic description of 
this case at the first session of the American Pediatric Society : The patient. 



150 DISEASES OF THE NEWLY-BORN. 

a female, was brought to the asylum as a foundling at age of five days. It 
was jaundiced, had sprue, and a rectal temperature of 9Qn° F. The efforts 
to increase its temperature were unavailing, and two days later it was care- 
fully examined. Its face was cold and rigid, and the coldness and rigidity 
had extended over not only the features, but the scalp, shoulders, arms, 
hands, hips, thighs, legs, and feet. The extremities were so stiff that pres- 
sure upon them or attempts to move them communicated the sensation of a 
cadaver or half-frozen tissue. Its eyes were closed ; its surface had a dirty, 
yellowish-brown color. When handled it uttered a feeble whimpering cry, 
but was otherwise motionless and quiet ; no pulse : rectal temperature below 
the lowest figure on the thermometer ; respiration feeble and shallow. Death 
occurred two days later, at the age of nine days. 

At the autopsy the sclerema was found to be less in the abdominal walls 
than elsewhere. On incising the hardened tissues no blood or serum escaped 
from the cut surface. The lungs had been fully inflated, no collapse being 
present, and they contained dark hemorrhagic points or spots. Nothing 
unusual was observed in the skull, brain, heart, and great vessels, the 
stomach, intestines, liver, and kidneys, except the urates in the tubuli 
uriniferse. The hemorrhagic extravasations in the lungs were found to con- 
sist of fresh blood in the alveoli and connective tissue. Dr. Northrup made 
microscopic examinations of the skin and subcutaneous tissues, and found 
that they took injections well, showing normal vascular network. The 
microscopic slides have been examined by expert microscopists and derma- 
tologists, and they can discover nothing abnormal that throws light on the 
cause or pathology of the sclerema. 

Sclerema bears considerable resemblance to oedema of the newly-born. In 
oedema the temperature is low and the cedematous tissues may present con- 
siderable firmness, but the surface usually pits on pressure, unlike that in 
sclerema. Of the different opinions expressed by observers in reference to 
the cause and pathology of sclerema, that expressed by Ludwig Langer in 
1881 (Wiener Sitziingsbericht, 1881) is the most plausible. It is as follows: 
In the adult oleic acid is the chief constituent of the adipose tissue, but in 
the newly-born the fat contains a large proportion of palmitin and stearin, 
which solidify when the heat of the body undergoes a moderate reduction 
below the normal. 

Infants having sclerema after lingering for days or weeks die in a state of 
extreme weakness. I am not aware that recovery has occurred in any case 
of genuine sclerema of the new-born. Still, it is proper to increase the tem- 
perature by warm applications to the body and limbs and to endeavor to 
improve the nutrition in every possible way. Perhaps a more abundant 
breast-milk or breast-milk of a better quality can be obtained, and a few 
drops of Tokay or other good wine or of brandy may be given every sec- 
ond hour. 

(Edema Neonatorum. 

In this disease thickening of the integument occurs and the subcutaneous 
connective tissue is infiltrated with serum. The oedema in most cases is at 
first in the legs, from which it extends along the thighs to the genitals. It 
may extend over the trunk, upper extremities, and cheeks, but in some cases 
it appears only in the hands and feet, producing tumefaction of the palms of 
the one and soles of the other. If the amount of serous infiltration be great, 
the tissues may be firm and resisting, communicating to the touch a sensation 
similar to that in sclerema ; but when the infiltration is less in degree the tis- 
sues are soft and doughy. The skin has a dusky or yellowish color, and 
sometimes, when much distended, it has a shiny appearance. In cases of 



PEMPHIGUS NEONATORUM. 151 

great oedema the movement of the affected part is diminished, but not to the 
same extent as in sclerema. As in sclerema, the temperature is below the normal. 
In fatal cases the adipose tissue is found of a brownish, yellowish, or 
reddish -yellow color, from which a yellowish serum exudes. (Edema of the 
newly-born does not appear to result from the same cause in all instances. 
Occurring in feeble, ill-nourished infants, it apparently results, in most in- 
stances, from extreme heart-weakness. The feeble circulation leads to venous 
congestion and consequent serous transudation. Pulmonary atelectasis, occur- 
ring as it usually does in ill-nourished and feeble infants, is also an occasional 
factor in producing venous stasis and transudation of serum. Elsasser has 
shown that occasionally in the newly-born the oedema results from nephritis, 
as it frequently does in the adult. Henoch relates the case of an infant of 
four weeks who had " marked oedema of face and limbs," with serous effu- 
sion in the pleural, pericardial, and peritoneal cavities, and compression of the 
left lower lobe, resulting from parenchymatous nephritis. Another occasional 
cause of the oedema is erysipelas. This cause is revealed by the dark-red 
color of the skin characteristic of erysipelatous inflammation. 

Recently Prof. Dumas in an elaborate paper on oedema of the new-born arrives 
at the following conclusions : " 1. (Edema of the new-born is only one of the symp- 
toms of a phlegmasia alba dolens which is developed during the first days after 
birth. 2. Its causes are of the same nature as in the adult, and may be divided 
into predisposins; and determining varieties. Among the latter, the principal one 
consists in the incomplete establishment of respiration or in the pathological or 
other causes which this function encounters. 3. The symptoms of phlegmasia in 
the new-born are the same as in the adult, excepting certain modifications with 
respect to the special physiology of the first days following birth. 4. The pathological 
anatomy is also about the same, but the venous thrombosis in the new-born is more 
frequently located in the inferior vena cava than it is in the same disease in the 
adult. - ' It does not seem improbable that Prof. Dumas' s explanation is applicable 
to a considerable proportion of cases, the formation of clots in the veins producing 
such obstruction and venous congestion that serum transudes as a consequence. 
Dumas recommends, in order to prevent this disease, " suitable care to effect respi- 
ration in the new-born at the moment of birth, and not too hasty ligation of the 
cord.*' 

(Edema, like sclerema, is ordinarily fatal, but occasionally, as when it 
results from erysipelas, recovery is possible. The treatment should be largely 
hygienic and dietetic. An abundant supply of good breast-milk should be 
obtained, or if this be impossible peptonized cow's milk. As in sclerema, 
artificial warmth and moderate alcoholic stimulation are required. 

Pemphigus Neonatorum. 

Pemphigus occurs in two distinct forms in the newly-born, which may be 
properly designated pemphigus simplex and pemphigus cachecticus. 

Pemphigus Simplex commonly occurs between the ages of two and twelve 
days. The vesicles, which vary in size from that of a pea to a hazel-nut. 
appear in some cases nearly simultaneously, but in other instances in suc- 
cessive crops. When fully developed, they ordinarily have a transparent 
yellowish color, and they may appear upon almost any part of the surface 
except the palms of the hands and soles of the feet. When the eruption is 
nearly general upon the surface, as it occasionally is, one or two blebs may 
even appear upon these parts, but as a rule in pemphigus simplex the palms 
of the hands and soles of the feet are not affected. 

In investigating the causes of this form of pemphigus we are struck with 
the fact that in a considerable proportion of the recorded cases those affected 
with it appear to be otherwise in perfect health. Occasionally in maternity 
hospitals it occurs as an epidemic. Thus, Ahlfeld observed twenty-five eases 



152 DISEASES OF THE NEWLY-BORN. 

during two months in an institution in Leipzig. The mothers of these infants 
were apparently healthy, and the pemphigus commenced in all between the 
second and fourteenth days after birth.. The palmar surfaces of the hands 
and plantar surfaces of the feet were not affected in any of these cases, 
though vesicles appeared on the fingers in some of them. Ahlfeld, from these 
observations, believed that the disease was infectious or of a miasmatic nature. 
Koch states that thirty-one cases occurred in the practice of a certain midwife, 
while in the practice of other midwives no case occurred. Weyl of Berlin, 
aware of facts like the above, states that the disease is undoubtedly conta- 
gious. Bohn, on the other hand, regards cutaneous irritants as a cause, and 
he states that the repeated occurrence of pemphigus in the practice of a cer- 
tain midwife was traced to the fact that she habitually used water too hot in 
bathing the infants. But there is now a sufficient number of observations to 
render highly probable, if they do not demonstrate, the contagious nature of 
pemphigus in certain cases. Boeser always found micrococci in the serum 
of the vesicles. Gribier found chain bacteria, single bacteria, and also bacteria 
in zooglea in the vesicles. Scharlau met the disease in different members of a 
family, and succeeded in inoculating himself from the vesicular contents. We 
may conclude, therefore, that pemphigus of the newly-born is probably in cer- 
tain cases microbic and inoculable, though the microbe which causes the disease 
has not been fully identified. But in some instances it is not improbable that 
the disease is produced by causes not microbic, as from cutaneous irritants. 
Further investigations in regard to the etiology of pemphigus simplex are 
required before positive statements can be made. 

Pemphigus simplex is usually attended by little constitutional disturbance, 
but sometimes, it is said, a slight fever attends the eruption of the vesicles. 
The skin adjacent to the vesicles may have the normal or a slightly congested 
or vascular appearance. The vesicular contents escape in a few days by 
rupture of the vesicle, or disappear by absorption, and the detached cuticle 
forms a thin scale which is soon thrown off, and in a few days replaced by a 
new growth of cuticle. 

Pemphigus Cachecticus. — This form of pemphigus occurs in infants who 
have a profound cachexia, and this cachexia is in a large proportion of cases 
due to inherited syphilis. Unlike pemphigus simplex, it attacks by preference 
the palms of the hands and soles of the feet, It also occurs upon thin por- 
tions of the skin, as the groin, axilla, and neck. The surface upon which the 
vesicles are situated presents a reddish or livid appearance, and the vesicles 
are only partially filled. The exuded liquid is not so clear as in pemphigus 
simplex, and it is often turbid or even bloody. The vesicles or remains of 
vesicles are sometimes observed at birth, and are then believed to have a 
syphilitic origin. When the cause is syphilis other manifestations of this 
disease may also be present. 

Pemphigus cachecticus may be prolonged several weeks, if the patient 
live, by the occurrence of new vesicles. It is important, as regards the 
selection of remedies, to bear in mind the fact that the profound dyscrasia 
which underlies and gives rise to an attack of pemphigus cachecticus may 
occur from other causes than syphilis, as perhaps struma. The evils which 
attend a family subjected to a life of poverty in a great city, as overwork, 
scanty and poor diet, overcrowding, and foul air, may be the cause of the 
dyscrasia in the infant born under such circumstances, even when the parents 
are actuated by the best motives and endeavor to lead a correct life. 

Anatomy. — The vesicles occur in the epidermis between the layers of the 
stratum granulosum and stratum lucidum (Weyl). The contents of the vesi- 
cles consist largely of serum, but sometimes also of other substances, as pus- 
cells, epithelial cells, etc. 



OSTEOGEXESIS IMPERFECTA. 



153 



Treatment. — This is simple, consisting of cleanliness, the use of abundant 
pure breast -milk, and frequent dusting of the surface with a powder consisting 
of bismuth and lycopodium. In the cachectic form of pemphigus, especially 
if the vesicles have an unhealthy appearance, they should be broken, and 
their surface may be dusted with a powder of one part of iodoform and ten 
of bismuth. In syphilitic cases Henoch recommends the addition of 1 gramme 
(15 grains) of corrosive sublimate to the bath employed. The use of a few 
drops of Tokay wine or other alcoholic stimulant at each nursing is also 
required in the cachectic cases. 

Osteogenesis Imperfecta. 

Cases have been reported in which bony substance was very deficient 
in the foetal development, so as to cause curvatures and deformities in the 

Fig. 16. 




skeleton. It has commonly been supposed that these cases are rachitic, and 
from them has arisen the belief that rachitis occasionally occurs in the foetus. 



154 



DISEASES OF THE NEWLY-BORN. 



Fig. 18. 



But recent microscopic examinations have shown that in at least some of 
the cases of supposed fetal rachitis, rachitis has not been present. Stilling 
published such a case in Virchow's Archiv. It is represented in Fig. 16 from 
Sajous' Annual, vol. ii., 1890. The skeleton, which was that of a female born 
at the eighth month, was very deficient in bone-substance, but without the 
characters of rachitis. Stilling suggests that the cause of this deficiency 
and malformation may have been syphilis. 

In the Wood Museum of Bellevue Hospital is a skeleton which is 
probably similar to those in the Prague and Wurzburg museums. It shows 
in a striking manner the deform- 
ities of this congenital disease. 
The case occurred in my practice, 
and the dissection was made by 
Prof. Francis Delafield. The in- 
fant, born at term, died a few 
hours after birth from atelectasis, 
apparently produced by the con- 
tracted state of the thoracic walls. 
The parents were hard-working 
English people. They were free 
from syphilitic taint. The accom- 
panying wood-cut (Fig. IV) repre- 
sents this skeleton. 




Fig. 17. 





Skeleton of an infant which died a 
few hours after birth (from the Wood 
Museum). 



Showing foetal deformity of skeleton without 
rickets. 



The following case (Figs. 18, 19) occurred in my service in the New York 
Infant Asylum. The child lived five hours, being kept alive by artificial res- 
piration. Its mother seemed healthy, but its father was unknown to the phy- 
sicians of the Asylum. The longitudinal section of the lower extremities, 
as is seen in the illustration and was proven by microscopic examination, 
made by Prof. Prudden, did not exhibit any of the characters of rachitis. 



OSTEOGENESIS IMPERFECTA. 



155 



Fig. 19. 



"~~^~ " 





/ 




r ■ 

Longitudinal sections of the bones of the lower extremities 



k 



PART III. 
CONSTITUTIONAL DISEASES. 



SEOTIONT I. 

DIATHETIC DISEASES. 



CHAPTER I 

RACHITIS. 



Rachitis is a constitutional disease, but its most conspicuous anatomical 
characters pertain to the osseous system. The gross nutritive changes which 
it produces in the bones and cartilages, causing deformities, are well known 
to physicians and the laity. In addition to these anatomical changes in the 
skeleton, typical cases exhibit a lack of tonicity with stretching of the liga- 
ments, causing the knock-knee and flat-foot ; weakness of the muscles, resem- 
bling paralysis are sometimes mistaken for it in severe cases ; reflex irrita- 
bility, rendering rachitic patients liable to laryngismus and tetany ; undue 
perspiration ; anaemia and proneness to catarrhal inflammation ; and certain 
anatomical changes in the spleen and liver in aggravated forms of the disease. 
These many and divers anatomical and functional characters indicate the 
constitutional or general nature of rachitis. Therefore theories which 
restrict rachitis to the osseous system are inadequate and erroneous. 

Rachitis is probably an ancient disease. It is said that an old statue of 
JEsop, who was thrown from a precipice by the indignant Delphians 564 years 
before Christ, exhibited rachitic deformities ; and Hippocrates, born 460 years 
before Christ, is believed to have alluded to it in his treatise on the Articu- 
lations. 

Occasionally expressions in the works of Celsus and Galen in the second 
century of the Christian era have led writers on rickets to believe that they 
also had observed the deformities produced by this disease. But rickets was 
first investigated in a scientific manner by Whistler, Glisson, and their con- 
temporaries in the middle of the seventeenth century. During the last few 
years many excellent monographs have been written on this malady, and its 
causation, pathology, and treatment are better understood than formerly. 

Frequency. — Rachitis is a widespread disease, but it is comparatively 
infrequent in rural localities, where families enjoy the hygienic requirements 
of pure air, sunlight, and a plentiful diet of good quality. It is most common 
in crowded and badly-fed families in city tenement-houses, where antihygienic 
conditions prevail. 

Mild cases of rickets, not manifested by any prominent signs or symp- 
156 



RACHITIS. 157 

toms are often overlooked, so that the physician is not summoned, or, if he 
be summoned and have not given particular attention to this disease, he, in 
not a few instances, does not detect its presence. In the absence of deform- 
ity, which occurs later, the fretfulness, tenderness of surface, and perspira- 
tions are likely to be attributed to other causes than the correct one. Hence, 
according to my observations, rachitis is more common in its milder forms in 
the asylums and dispensaries and in the tenement-houses of New York, and 
probably in other American cities, than is commonly believed by the laity, 
and even by physicians who have given little attention to the disease. A few 
years since in one of the New York asylums my attention was directed to a 
rachitic child in whom the anatomical characters of rachitis had become so 
pronounced that they attracted the attention of the nurses. Prompted by 
the occurrence of this case, which had developed during my attendance in the 
asylum, I made an examination of all the infants, and found, what I had 
previously not suspected, that about one in nine presented unmistakable signs 
of rachitis, though in a mild form and for the most part in its commencement. 
The late Dr. John S. Parry of Philadelphia stated that at least 28 per cent, 
of the children between the ages of one month and five years who came 
under his observation in the Philadelphia Hospital, during the three years 
preceding the publication of his paper in 1872, were rachitic. According to 
Dr. Gee, whose observations were, however, made as far back as 1867 and 
1868, of the patients under the age of two years in the London Hospital for 
Sick Children, 30.3 per cent, were rachitic ; and Ritter von Rittershain, whose 
observations were also made several years ago, stated that of 1623 out-door 
patients under the age of five years brought to the Clinique at Prague, 504, 
or 31.1 per cent., manifested this disease. Recently Prof. Henoch of the 
University of Berlin has stated that he had seen many thousand cases of 
rachitis, and he adds that its spread in the large cities of Northern and Mid- 
dle Europe is enormous. He states that his observations in regard to the 
frequency of rachitis in dispensary practice correspond with those of Von 
Rittershain, as many as 31 per cent, being rachitic. In Manchester also, 
with its large number of operatives, Ritchie's statistics show that of 728 out- 
door patients 219 were rachitic. The late curator of the New York Foundling 
Asylum, who served ten years, informs me that he believes, without the accu- 
racy of statistics, that as many as 20 per cent, of the cadavers examined by 
him in the dead-house presented the anatomical characters of rachitis, usually 
in a mild form. 

The recent large emigration from Europe of destitute families, living from 
choice or necessity in filth and degradation, who for the most part remain in 
the cities, occupy small, dark, and dirty apartments, and whose food is of the 
poorest quality and often insufficient, greatly increases the number of rachitic 
children in New York and probably in other American cities. In the out- 
door department of Bellevue, to which many thousand immigrants from the 
lowest class of European society carry their sick children for treatment, 
rachitis is not infrequent ; and the fact has been observed in this institution 
that a larger proportion of severe cases attended by marked deformities occur 
in the Italian families than in those from other parts of Europe. In families 
of American parentage it is generally admitted that rachitis is more prevalent 
in the negro than in the white race. 

Although this disease occurs most frequently in the families of the desti- 
tute and poorly fed, nevertheless children of well-to-do families occasionally 
suffer from it, even in an aggravated form, in consequence, I think, usually 
of ignorance on the part of parents in regard to the dietetic requirements oi' 
young children. Merei, in his treatise on the Disorders of Infantile Develop- 
ment (London, 1850), states that in Manchester, where his observations were 



158 CONSTITUTIONAL DISEASES. 

made, one child in every five in comfortable circumstances presented rachitic 
symptoms. In the United States rachitis is rare in well-to-do families, who 
provide sufficient and suitable diet for their children and have a proper regard 
for sanitary requirements. When it does occur in such, it is due usually, 
I think, to improper feeding. But this cause will be discussed in another 
place. 

Diagnosis. — In preparing statistics relating to rachitis it is obviously 
important that the diagnosis of mild and incipient cases should be clear and 
unmistakable. What symptoms and anatomical characters indicate rachitis? 

The fact that an infant has reached its ninth month without a tooth is 
regarded by Sir William Jenner as a reliable sign of rachitis. In order to 
determine to what extent dentition is retarded by rachitis — and retarded 
dentition may be considered a sign of rachitis — Dr. H. R. Purdy, physician 
to the Out-door Department of Bellevue Hospital, made the following obser- 
vations : 

Table I. — Showing at what Age 200 Infants exhibiting no signs of Rachitis 
cut the First Tooth — cases consecutive. 

3 cut first tooth at 2 months. 28 cut first tooth at 8 months. 

14 " " " " 3 " 20 " " " " 9 

16 " " " " 4 " 14 " " " " 10 

20 " " " " 5 " 15 " " " " 11 

24 " " " " 6 " 8 " " " " 12 

37 " " " " 7 " 1 " " " " 13 

Of these, 132 were wet-nursed. 68 bottle-fed. 

Table II. — Showing at what Age 50 Infants exhibiting one or more Rachitic 
Symptoms cut the First Tooth — cases consecutive (18 wet-nursed, 32 bottle- 
fed). 

2 cut first tooth at 4 months. 7 cut first tooth at 11 months. 

2 " " " " 5 " 

3 " " " " 6 " 

O a n a (< - u 

5 " " " " 8 " 

6 " " " " 9 " 

Table III. — Thirty Infants with Teeth, but with pronounced Rachitic Symp- 
toms. In all these cases the rachitic rosary, enlarged subcutaneous veins, 
profuse perspirations, abdominal distention, and enlarged joints were pres- 
ent. Bottle-fed, 21 ; wet-nursed. 9. Age at which they cut the first tooth. 

6 at 7 months. 3 at 12 months. 

10 " 8 " 2 " 13 " 

1 " 9 " 2 " 14 " 

1 " 10 " 1 " 15 " 
4 " 11 " 

It is evident from these interesting statistics that dentition delayed until 
the ninth, or even the tenth or eleventh month, is not a certain sign of rachi- 
tis, but slow teething is common in the rachitic, and therefore it aids in the 
diagnosis. It is one of the diagnostic signs. 

In order to determine whether rachitis incipient or of a mild form be 
present, all the signs which characterize it should be considered — the fretful- 
ness. free perspiration upon the head. neck, face and chest, the tenderness of 
surface, anaemia and general deterioration of health, delayed dentition, swell- 
ing of the joints, craniotabes. bending of the long bones, rachitic rosary, mis- 



5 


" 


i a 


"12 * 


6 


a 


i a 


" 13 ' 


3 


a 


( a 


" 14 < 


1 


it 


i a 


" 16 < 


1 


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i n 


" 18 < 



RACHITIS. 159 

shapen head, prominent frontal and parietal bones, deformity of the thorax 
with depression of the ribs, projecting or misshapen sternum and prominent 
abdomen, with Harrison's groove. All these signs and symptoms must be 
considered before making a diagnosis in incipient or mild rachitis. In order 
to determine the diagnostic value of enlargement of the costo-chondral articu- 
lations. " the rachitic rosary," I have examined these joints in children sup- 
posed to be healthy or suffering from other ailments than rachitis in three of 
the New York institutions. In many young children believed to be healthy 
who were examined, these joints were not appreciable on palpation. In others 
a slight prominence could be felt in one or more joints. In order that the 
beading of these articulations be sufficient to indicate rachitis, it should, I 
think, be plainly detected by the fingers in most of the costo-chrondral articula- 
tions. Less than this I would not regard as sufficient evidence of this disease. 

Age of Occurrence. — Deficiencies and curvatures in the bones of the newly- 
born have until recently been supposed to result from foetal rachitis. But 
microscopic examination of some of these cases has demonstrated beyond 
doubt that the disease present was not the result of rachitis, but an osteo- 
genesis of unknown origin. This disease is described in the preceding chapter. 

Enlargement of the costo-chondral articulations, known as the rachitic 
rosary, has been observed, though rarely, in infants only a few weeks old. 
Dr. Parry saw it as early as the sixth week after birth, and Dr. Lee at the 
third or fourth week. The significance of this enlargement as a sign of rachi- 
tis we have treated of elsewhere. We have stated that with few exceptions 
rachitis begins before the close of the third year. Though first detected and 
diagnosticated at a later date, it will ordinarily be ascertained, on inquiry, that 
its symptoms had an earlier beginning. Still, according to certain observers, 
it may have a considerably later commencement. Glisson, Portal, and Tripier 
state that they have seen it commence in children who were well on toward 
the age of puberty. Sir William Jenner says that he has seen children of 
seven and eight years who were only beginning to suffer from rachitis. 

The following are the aggregate statistics of Bruennische, Von Bitters- 
hain. and Bitsche relating to the age at which rachitis occurs : 

No. of Cases. 

During the first half year 99 

" " second half of first vear 259 

" year . .* 342 

" " third year 134 

" " fourth year 31 

" " fifth year 17 

Between the fifth and ninth years 21 

Aggregate 903 

Etiology. — Inheritance. — Some patients with rachitis appear to have 
inherited a predisposition to it. Feeble digestion and defective assimilation 
in the infant — which are, as we will see, important factors in producing the 
rachitic state — are often traceable to disease or cachexia of one or both 
parents. Among the parental causes may be mentioned poverty, hardships, 
and defective nutrition of either parent ; age of father and exhausting dis- 
charges of the mother, such as purulent, hemorrhoidal, or uterine fluxes. 
The offspring of a tubercular, syphilitic, or otherwise enfeebled parent is more 
likely to become rachitic than is one of healthy and robust ancestry. We 
will especially emphasize the syphilitic dyscrasia in either parent as a potent 
cause, but M. T. Parrot, in his thesis published in 1872. evidently went too 
far in attempting to show that congenital syphilis is the common cause oi" 
rachitis. Most rachitic cases are entirely free from the syphilitic taint, and 



160 CONSTITUTIONAL DISEASES. 

a large proportion of the children who have inherited the syphilitic dyscrasia 
do not exhibit any signs of rachitis. 

Antihygienic Conditions. — In the damp, dark, filthy, and overcrowded 
tenement-houses of the city, rickets occurs most frequently and in its sever- 
est forms. There can be no doubt that general mal-hygiene is a potent 
factor in causing this disease, and that it sometimes produces it in those who 
have inherited good constitutions. On the other hand, many children with 
healthy parentage and vigorous at birth, reduced by poverty to a life of 
squalor and privation, do not become rachitic. 

Food. — Of the antihygienic conditions which give rise to rachitis, the 
most common and potent appears to be the use of food not sufficiently nutri- 
tious, or, if nutritious, not suited to the age and digestive powers of the child. 
The use of thin and poor breast-milk and artificial food of poor quality or not 
suitable for the stage of growth and development is a common cause of 
rachitis. Those children who have been prematurely weaned, and who have 
been given food which is not a proper substitute for the natural aliment, and 
those too long wet-nursed by scantily-fed and poorly-nourished mothers, and 
not allowed the additional aliment which they require, are especially liable to 
this disease. Those children whose digestive power is feeble, from whatever 
cause, are more likely to become rachitic than those who in a state of robust 
health have a hearty digestion. Hence we meet with rickets as a sequel of 
various protracted and exhausting maladies during infancy. 

I might relate cases of rachitis occurring during the use of certain of the 
popular proprietary or commercial foods. I have examined the analyses of 
these foods made by Prof. Leeds in order to determine what ingredient is 
lacking, and they are found to contain a considerably smaller percentage of 
fat than occurs in human milk. Too little fat in the food may, as Cheadle 
observes, be one of the chief dietetic causes of rachitis. Infants suckled by 
healthy mothers or wet-nurses who have an abundance of milk, of good 
quality, do not become rachitic as long as their nutriment is derived from 
this source. But those prematurely weaned and given a diet deficient in 
nutritive properties, and those who are allowed the promiscuous food of the 
table or have largely a farinaceous diet during the first and second years, 
when the food should be chiefly milk, are especially liable to become rachitic. 

It is an interesting fact, and one that throws light on the dietetic cause 
of rachitis, that it does not occur in Japan. Physicians who have had 
abundant opportunities to observe the diseases of the Japanese state that 
they have never seen or heard of a case among them. M. Remy, in his Notes 
Medicates sur le Japon, says that the Japanese women have a remarkable 
abundance of milk, and that they suckle their young until the age of five or 
six years, but their children are also given artificial food after the first year. 
Remy's explanation of the immunity of the Japanese from rachitis is as fol- 
lows : " The Japanese have always eaten plentifully of fats and oil of fishes, 

the blubber of the whale, the eel and loach especially The universal 

use of the food under notice from the time of ancient Buddhist flesh-prohibi- 
tion, but especially the consumption of fish by the lactating women, together 
with the fish given to the children as supplementary feeding, which at that 
time is allowed them by Japanese tradition, are, in my opinion, main causes 
of the non-existence of rachitis in Japan." 

Observations on the feeding of animals have also aided in the elucidation 
of the causation of rachitis. Guerin gave certain puppies a diet of meat four 
or five months, and they became markedly rachitic, while other puppies of the 
same litter, suckled by their mother, remained well. At a meeting of the 
section of Diseases of Children of the British Medical Association, held in 
August, 1888, Dr. W. B. Cheadle read an instructive paper on rachitis, in 



BACHITIS. 161 

which he said that the results of feeding young animals in the Zoological 
Gardens strongly support the view that a deficiency of animal fats and earthy 
salts are the most efficient agents in producing rickets. He states that in the 
Zoological Gardens the young monkeys taken from their mothers and fed 
with a vegetable diet, chiefly fruits, become rachitic. Such diet is destitute 
of animal fat, and is deficient in proteids and earthy salts. Two young bears 
were fed with rice biscuits, and occasionally with lean meat, which they 
licked but rarely ate. Fat, proteids, and lime salts were practically excluded 
from their food. The bears died of extreme rickets while still young. Cheadle 
also states that more than twenty litters of lions had died successively of 
rachitis, and the next brood were fed with cod-liver oil, pulverized bones, and 
milk. In three months all signs of rickets had disappeared. The addition 
of fat and bone-salts caused the change, and after eighteen months, when the 
last observations were made, the brood of young lions were strong and 
healthy. They had received in every respect the same treatment as the 
litters that had perished, except as regards the diet. The latter had been 
fed with the carcasses of old horses, which are destitute of fat and whose 
bones resisted the lions' teeth. 

The theory that lactic acid is the causal agent in rachitis has been strongly 
advocated by Dr. C. Heitzmann, formerly of Vienna, but now of New York. 
He administered lactic acid by mouth and subcutaneous injection to five dogs, 
seven cats, two rabbits, and one squirrel. The lactic acid administered to the 
dogs and cats, with " restricted administration of calcareous food," produced 
the characteristic enlargement of the epiphyses, and finally the " curvatures 
of the bones of the extremities." After four or five months of administration 
of lactic acid the long bones were very flexible, and repeated inflammations 
of the conjunctiva, bronchi, stomach, and intestines had occurred. 

But in many cases of rachitis there is no evidence of an excess of lactic 
acid, and an objection to the lactic-acid theory apparently valid is that lactic 
acid, produced by imperfect digestion, would unite with a base, either the 
soda or potash in the blood, which is always alkaline, before it reached the 
osseous system. The more the causation of rachitis is elucidated by observa- 
tions on man and experiments on animals, the stronger is the evidence that 
its chief cause is dietetic — that there is a failure to receive or to digest and 
assimilate certain important substances in the food, particularly the fat, phos- 
phate of lime, and proteids. The deprivation of these alimentary substances 
produces the rachitic dyscrasia, which is manifested by malnutrition in many 
tissues. Of course general antihygienic conditions, which lower the vitality, 
may, as we have stated elsewhere, be a factor in causing rachitis. 

Pathology. — Distinguished pathologists and clinical observers who have 
investigated rachitis, and whose investigations have been chiefly, if not 
entirely, restricted to the osseous system, have regarded this disease as an 
inflammation affecting the bones and cartilages. i\.mong those who have ex- 
pressed this opinion may be mentioned Virchow and Niemeyer. Niemeyer 
says : " It seems to me that the most probable hypothesis regarding the cause 
of rachitis is that which refers it to inflammation of the epiphyseal cartilages 
and periosteum." The increased vascularity of the periosteum, the prolifera- 
tion of periosteum and cartilage, the tenderness and pain on motion, and the 
elevation of temperature in acute forms of the disease, indicate inflammation 
rather than any other recognized pathological state. If the rachitic disease 
of the osseous system be regarded as an inflammation, it obviously presents 
a subacute or chronic character, like cirrhosis and certain forms oY chronic 
nephritis, in which proliferation of connective tissue and sclerosis occur. The 
eburnation, instead of normal ossification, which terminates the rachitic pro- 
cess, might be considered an osteosclerosis. Moreover, the thickening, hyper- 
11 



162 CONSTITUTIONAL DISEASES. 

aemia, and infiltration of the periosteum, exudation and formation of new 
vessels in the periosteum and underlying cartilaginous and osseous tissues, 
are conformable with the theory of the inflammatory nature of rachitis. On 
the other hand, some of the structural changes in the soft tissues in rachitis 
which are described in this paper are not such as ordinarily result from 
inflammatory processes. Billroth, seeing the difficulties in the way of the 
inflammatory theory, wrote of rachitis that it " cannot be exactly classed 
among the chronic inflammations, although nearest related to this process." 
It seems most in consonance with the facts to regard rachitis as a constitu- 
tional or general disease, a dyscrasia affecting the nutrition of various tissues 
of the body, and producing disease in the osseous system which is either 
inflammatory or closely allied to inflammation. 

Changes in the Soft Tissues. — We have stated that although the con- 
spicuous lesions of rachitis pertain to the skeleton, the soft tissues are also 
more or less implicated, as might be expected, since the disease is systemic in 
its nature. The skin in milder cases is but little involved, but as a rule the 
perspiration of the rachitic is excessive from the head, face, neck, and chest. 
This may occur before changes are observed in the skeleton. Pyrexia is in 
some patients absent or slight, but catarrhs of the mucous surfaces are com- 
mon, and these are likely to give rise to some elevation of temperature. The 
fever that frequently accompanies severe cases may sometimes result from 
the disease of the skeleton. In protracted and severe cases the patients 
become markedly anaemic, but in recent and mild cases the pallor may be so 
slight as not to attract attention. Emaciation is not pronounced, as a rule, 
in the rachitic, but in certain patients the muscles throughout the system 
become shrunken and flabby, partly perhaps in consequence of the gastro- 
intestinal disorder, indigestion, and malnutrition, partly perhaps from want 
of use, for the rachitic are likely to be passive. 

Mucous Membranes. — Rachitis, as we have stated above, increases the 
liability to catarrh of the mucous surfaces. Writers on this disease have 
remarked the frequent occurrence of bronchitis, broncho-pneumonia, entero- 
colitis, and conjunctivitis. 

Ligaments. — The ligaments become relaxed and flabby, giving unusual 
mobility to the joints and unsteadiness to the movements. The fibrous bands 
which unite the vertebras, as well as the ligaments of the extremities, partici- 
pate in the relaxation. Talipes valgus and knock-knee are especially likely 
to occur in rickets as a result of the relaxation of ligaments, even when the 
bones are but slightly involved. Kyphosis, lordosis, and scoliosis — backward, 
forward, and lateral curvatures of the spine — also result from relaxation of 
the ligaments, aided by the softening and change in shape of vertebrae and 
of the intervertebral cartilages. 

The Spleen and Liver. — The spleen is sometimes enlarged, as ascertained 
by palpation and percussion. Hitter von Rittershain found this organ de- 
cidedly enlarged in 10 out of 35 cases which he examined after death. The 
enlargement is the result of cellular proliferation, common in diseases which 
are attended by a dyscrasia. In a recent very anaemic and fatal case of 
rachitis in the New York Foundling Asylum the spleen extended below the 
level of the umbilicus. But in many cases of rachitis, even when profound, 
splenic enlargement is slight or is not appreciable. 

The liver in many patients undergoes no perceptible change, except that 
it is carried downward by the lateral depression of the ribs. It is occasion- 
ally enlarged from fatty infiltration, but no special significance attaches to 
this, for fatty liver is common in various forms of disease attended by innu- 
trition and wasting. It is common in tuberculosis and in protracted intestinal 
catarrh, and its pathological significance appears to be the same in these 



RACHITIS. 163 

various diseases. There can be no doubt that Sir William Jenner errs when 
he states that albuminoid infiltration of the liver is common in rachitis. 
Parry, Gee. Dickinson, and Senator agree that it is rare, and that when it 
does occur it is a coincidence. 

In the discussion of rickets at the meeting of the British Medical Asso- 
ciation in August, 1888, Dr. Ranke of Munich said that, according to the 
records of 34 post-mortem examinations of rachitic cases in Virchow's Patho- 
logical Institute between 1872 and 1880, 13 exhibited changes in the liver, 
mostly parenchymatous fatty infiltration with increase of volume. In the 34 
cases the spleen was recorded enlarged in 9 and small in 2. In the remaining 
23 cases the size and appearance of the spleen were probably normal, or some 
mention would have been made of it. Dr. Ranke also consulted the records 
of the Munich Pathological Institute under Prof. Bollinger, and in 9 of 25 
post-mortem examinations of rachitic cases more or less enlargement of the 
liver was recorded. We may therefore infer from these carefully conducted 
examinations that enlargement and structural changes of the liver and spleen 
only occasional^ occur in rachitis — that in the majority of cases this disease 
runs its course without any notable alteration in these organs. My own 
observations lead me to believe that hypertrophy of the spleen, and probably 
also of the liver, occurs chiefly in decidedly anaemic subjects. 

The abdomen is protuberant from various causes. The lateral depression 
of the thoracic walls causes the liver and spleen to descend a little lower in 
the abdominal cavity than natural, producing at the base of the chest ante- 
riorly Harrison's groove, which is transverse and corresponds with the inser- 
tion of the diaphragm. The enlargement of the liver and spleen, the feeble 
tonicity of the intestinal muscular fibres, and consequent distention of the 
intestines with gas, and the rachitic shortening of the spinal column, which 
causes approximation of the ribs and pelvis, necessarily produce abdominal 
protuberance. 

The Kidneys and Urine. — Observations thus far have not detected any 
structural change or disease of the kidneys attributable to rachitis, except 
that this organ is enlarged in some cases. Moreover, the records of the urine 
are so conflicting that more exact and more numerous examinations of this 
excretion are required before any positive statement can be made in reference 
to its composition. Dr. C. H. Flagge has seen two cases in which there were 
large quantities of uric acid in the urine. Ephraim also mentions an increased 
elimination of uric acid up to 18 per cent. Ephraim likewise, as well as Mar- 
chand and Lehmann, state that there is an increase of phosphate of lime and 
the occurrence of lactic acid in the urine. 

Brain and Spinal Cord. — It is not improbable that the symptoms of 
rachitis which are referable to the nervous system, such as laryngismus 
stridulus, tetany, convulsions, and weakness or paralysis of the extremities, 
may be largely due to the pressure exerted in places upon the cerebro- 
spinal axis by its bony covering. Hence we will postpone their considera- 
tion until we have described the changes produced by rachitis in the osseous 
system. 

Changes in the Osseous System. — A knowledge of the normal anatomy 
and normal development of the osseous system will enable us to better under- 
stand the changes which occur in this system in disease, and especially, which 
concerns us at present, in rachitis. Hence we will give a brief resume of the 
anatomy of the skeleton in health before we consider the changes produced 
in it by rachitis. 

Osseous System, in Health. — In health and when fully developed, bone con- 
sists of animal matter (chiefly gelatin) and earthy salts, in the proportion, by 
weight, of about one part of the former to two of the latter. The following 



164 CONSTITUTIONAL DISEASES. 

is the analysis, which may be regarded as approximately correct, of healthy 
human bone of the adult : 

Animal matter 33.30 

Tribasic phosphate of calcium . . .51.04 

Carbonate of calcium 11.30 

Fluoride of calcium 2.00 

Phosphate of magnesium 1.16 

Soda and chloride of sodium . . . . 1.20 

100.00 



Earthy salts. 



In childhood the bones are softer, more elastic, and less likely to fracture than 
in the adult. Of the earthy salts in bone, it is seen that the phosphate of 
calcium is the most abundant, and it is the most important. Hence it is 
termed "bone earth." The phosphate of calcium, combined with animal 
matter, produces a hard compound. The enamel of the tooth consists chiefly 
of phosphate of calcium (88* per cent.), while the softer egg-shell consists 
chiefly of the carbonate of calcium. The strength of bone is remarkable, 
being, according to Holden, when compared with wood, nearly three times 
that of the elm or ash, and double that of the oak. It is elastic on account 
of the animal matter which it contains. If a long bone be placed at right 
angles upon a hard substance, and the projecting end receive a blow from a 
hammer, the latter will rebound. The Arab children are said to make bows 
of the camel's ribs. 

If a longitudinal section be made through a long bone, we observe a hard 
or compact outer part, and in the interior the medullary canal, containing 
marrow. In birds of flight the hollow of the bones contains air instead of 
marrow, and this air communicates with the lungs. 

The hard or compact portion of bone, though solid like a stone, consists 
of layers in close apposition, so that there is no interval between them. On 
approaching the joints the internal layers of the compact structure separate 
from each other, forming the cancellous tissue, so that the compact wall 
becomes thinner. If the earthy salts be removed by an acid, the animal 
matter remaining is found to consist of layers, which can be separated from 
each other. In inflammation the afflux of blood and the exudation cause 
separation of the layers and enlargement of the bone. 

The cancellous tissue occupies the interior of the bone, and is most abun- 
dant in its articular ends. The bony layers in the cancellous structure are 
separated from each other, so as to form cavities, which are strengthened by 
cross-plates like latticework. In the adult the marrow in the interior of the 
shafts of the long bones is yellow, consisting of 96 per cent, of fat, but in 
the articular ends of the long bones, in the ribs, cranial bones, and short 
bones, the marrow has a reddish tinge, and it consists of about 75 per cent, 
of water and about 25 per cent, of albumin, without fat or only a trace of it. 
This kind of marrow occurs in all the bones of the foetus and the infant, and 
it contains cells with many nuclei, designated " myeloid cells." Holden says 
that bones are as minutely provided with blood-vessels and nerves as are the 
soft tissues. Near the extremities of the long bones are numerous minute 
openings through which blood is conveyed to and from the cancellous tissue. 
On the shafts of the long bones are slight grooves parallel with the shafts, 
at the bottom of which are minute holes, scarcely visible, through which 
blood is conveyed to and from the compact tissue. The blood which supplies 
the osseous tissue is conveyed through these holes by minute arteries from 
the vessels of the periosteum, and is returned by veins to the periosteum. 
Xear the middle of the shaft of the long bone is a distinct canal passing 
obliquely through the shaft. This canal contains the nutrient artery of the 



RACHITIS. 165 

medulla, dividing, after entering the medullary cavity, into two branches, one 
passing upward and the other downward. The blood-vessels supplying the 
different parts of the bone from these various sources intercommunicate. 
Other bones than the long bones are supplied with blood in a similar man- 
ner, and the nutrient vessels are accompanied by nerves, as in other parts 
of the system. 

The microscope is required in order to reveal the minute anatomy of bone. 
It is found to consist of canals, termed the Haversian, and around each canal 
the bone is arranged in concentric layers, like the concentric rings of a tree. 
Between the rings are dark spots, designated lacunae, arranged concentrically, 
now known to be minute reservoirs containing blood. Minute lines are seen 
connecting the reservoirs with each other and with the adjacent Haversian 
canal. The lines are minute blood-vessels, and through them the blood is 
conveyed to every part of the bone. They are designated canaliculi. They 
connect externally with the vessels of the periosteum, and internally with the 
vessels of the medullary membrane or endosteum. In the interspaces between 
the lacunaB and canaliculi, in the animal matter, an infinite number of osseous 
granules is deposited, consisting mainly of phosphate and carbonate of lime. 

Alterations in the Osseous System in Rachitis. — For convenience of descrip- 
tion the course of rachitis as regards the osseous system is divided into three 
periods : (1) That of proliferation and altered nutrition of cartilage and perios- 
teum : (2) That of curvature and deformity ; (3) That of reconstruction. 

1. Anatomical Characters in the Stage of Proliferation and Altered 
Nutrition. — The long bones in normal growth increase in length by the form- 
ation of bone in the cartilage between the diaphysis and epiphysis, and in 
thickness by the development of bone from the vascular and cellular under- 
surface of the periosteum. As regards the flat and short bones, growth in 
the thickness occurs from the periosteum, and growth in breadth occurs from 
the development and ossification of the cartilaginous borders and edges, which 
correspond with the epiphyseal cartilage of the long bones. 

If we examine the epiphyseal cartilage of a long bone during normal 
ossification, we observe, beginning at the distal end, a white zone, consisting 
of the hyaline matrix, in which are the usual cartilage-cells. This consti- 
tutes most of the cartilage. Underneath this, and nearer the bone, is the 
zone of proliferation, the cartilage in which is softer and more yielding than 
that of the distal zone, in consequence of cell-formation and absorption of 
the matrix to make way for cell-groups. Each cell in the proliferating zone 
has divided into two cells, and each of these cells into two other cells ; and 
the division has been repeated, so that eight cells instead of one are observed, 
surrounded by a common capsule. The capsule becomes distended by the 
cell-multiplication and swelling of each cell, the size of which is considerably 
greater than that of the parent cell. Near the bone, along the extremity of 
the diaphysis, the cell-groups, enclosed in their capsules, nearly touch each 
other, the matrix having been for the most part absorbed. The end of the 
diaphysis is covered with a layer of these cell-groups about to undergo ossifi- 
cation, with almost no intervening matrix. The proliferating zone has very 
little depth. It appears to the naked eye as a very thin, scarcely perceptible 
layer of a reddish-gray color upon the end of the shaft. It is so thin that it 
but slightly increases the thickness of the cartilage. 

In rachitis the state is different. The zone of proliferation, instead o\' 
being confined to a single or at most double layer of cell-groups, consists of 
many layers, involving nearly the whole epiphyseal cartilage. The cells, still 
enclosed in their capsules, undergo a more frequent division than in health, 
so that, instead of groups of eight cells, as in the normal state, each group 
consists of thirty or forty cells enclosed in the distended capsule. There tore 



166 



CONSTITUTIONAL DISEASES. 



in rachitis the proliferating cartilaginous zone is a broad cushion, very soft, 
of a grayish translucent appearance, causing the characteristic swelling 
observed around the joint. Over the distal end of the proliferating carti- 
lage there may still be a zone, though perhaps of little depth, of normal 
cartilage like that in health. 

While the changes described above occur in the cartilages, the ossifying 
process is arrested or rendered abnormal. We indeed perceive an effort in the 
direction of bone-formation. The Haversian canals, surrounded by capillary 
loops, extend from the bone into the proliferating zone of cartilage. Their 
extension is effected by absorption of the matrix and appropriation of cell- 
groups which lie in their way. The cells in these groups, as they enter the 
Haversian system, become much smaller by rapid segmentation, forming 
medullary cells. We also find, as further evidence of the attempt at bone- 
formation, granules and masses of lime scattered through the cartilage, and 



Fig. 21. 



Fig. 20. 





\ 




n 





here and there spiculse and nodules of true bone springing up from the bony 
substance of the shaft. Some of the canals are prolonged far into the carti- 
lage — nearly, indeed, to its free surface — but most of them terminate in its 
lowest portions. 



RACHITIS. 



167 



We have stated that the growth of bone in thickness occurs from the 
under surface of the periosteum. In health a soft, vascular germinal tissue 
springs from the periosteal surface, rapidly receives lime salts, and is trans- 
formed into bone. This germinal tissue, consisting largely of capillaries 
rising from the fibrous tissue of the periosteum, is a very thin substance, 
barely visible, transient, and constantly changing from its conversion into 
bone. 

In rachitis this vascular subperiosteal tissue, not undergoing, or under- 
going slowly and imperfectly, the osseous transformation, and at the same 
time increasing more rapidly than in health under the irritating influence 
of the rachitic disease, becomes a thick layer. Its color and appearance 
are like spleen-pulp, so that the older observers supposed that there was 
hemorrhagic extravasation between the periosteum and the bone. There is, 
however, no extravasation of blood, unless it accidentally occurs from the 
numerous delicate capillaries. The resemblance to extravasated blood or 
spleen-pulp is due to the abundant growth of large and thin-walled capil- 
laries from the under surface of the periosteum, as shown by the microscope. 
This vascular outgrowth is, for the most part, quite uniform over the shafts 

Fig. 22. 




of the long bones, while upon the cranial bones its thickness is much greater 
in one locality than in another. The attempt at ossification also appears in 



168 



CONSTITUTIONAL DISEASES. 



this tissue. Lime salts are scantily and loosely deposited through it, forming 
osteophytes, vascular and fragile, rather than true bone. The question 
naturally arises, How does rachitis affect bone which is already formed when 
the rachitic state begins ? Virchow's answer is the following : " Rachitis 
has by more accurate investigation been shown to consist, not in a process of 
softening in the old bone, as it has previously been considered to be, but in a 
non-consolidation of the fresh layers as they form : the old layers being con- 



Fig. 23. 




sumed by the normally progressive formation of medullary cavities, and the 
new remaining soft, the bone becomes brittle/' 

We have seen that in healthy bone the earthy salts are in excess of 
organic matter nearly in the proportion of two to one, but in rachitis the 
proportion is reversed, the organic matter being much in excess. The follow- 



RACHITIS. 169 

ing table gives analysis of rachitic bones by Marchand, Davy, Boettger, and 
Friedleben : 

Femur. Radius. Vertebra. 

Inorganic. Organic. Inorganic. Organic. Inorganic. Organic. 

Case 1 20.60 74.40 21.24 78.76 18.68 81.32 

Case II 37.80 62.20 20.00 80.00 32.29 67.71 

Case III 20.89 79.11 

Case IV 52.85 47.15 

As might be expected, the relative proportion of the inorganic matter (the 
earthy salts) and the organic matter varies greatly in different cases. In 
severe rachitis many bones are affected. It is stated that there is no bone in 
the entire skeleton that may not suffer, but in mild cases only a few are 
involved, at least to such an extent as to produce structural changes appre- 
ciable to touch or sight. 

Rachitic bone, when the disease is still in its active period, presents a 
bluish or dusky-red appearance from its increased vascularity. After a vari- 
able time — weeks or months according to the severity of the disease — deform- 
ities begin to appear. 

2. Anatomical Characters of the Rachitic Child.— In typical rachitis 
the bone seldom retains its normal form or shape : its projecting points are 
rounded, and as soon as it softens it begins to yield to pressure exerted upon it. 
Hence the curvatures so common and characteristic. The portion of a long 
bone which is formed after rachitis commences contains so little earthy matter 
that it bends readily in its fresh state either by muscular action or by the 
weight of the trunk, " in the manner," says Vogel, " of a quill or willow 
stick." The interior of the bone, which was formed before rachitis began, 
and which contains nearly or quite the normal proportion of lime, is likely 
to break instead of bend, but, as it is surrounded on all sides by the soft 
tissue, the fragments are not displaced, and probably do not crepitate. So 
scanty is the calcareous deposition in typical cases that, says Trousseau, 
" the bones .... can be cut with a knife with as much ease as a carrot or 
other soft root,'' and the dried specimen weighs from one-sixth to one-eighth 
of the weight of normal bone. One writer states that the dried rachitic bone 
is sometimes so porous from the small amount of lime which it contains that 
it is possible to respire through it as through a sponge. 

In ordinary cases the bones which exhibit most strikingly the rachitic 
change, and which, therefore, should be examined carefully in making the 
diagnosis, are the cranial bones, the ribs, and the radius — the sternal ends of 
the ribs and the lower end of the radius. It is seldom that these bones do 
not give evidence of the disease if it be present, and in greater degree than 
other bones. They are the first to be affected to an extent that is appreciable 
to the observer. 

Changes in the Cranial Bones. — In these bones interesting and important 
alterations occur. Their edges which correspond with the epiphyseal carti- 
lages of long bones, undergo proliferation, and become thickened like the 
latter. This thickening and the delayed union of the sutures produce grooves 
which can be traced by the fingers between the bones, and which are some- 
times appreciable to the sight. Rachitis causes enlargement of the cranium. 
but the enlargement seems greater than it really is, on account of the retarded 
growth of the facial bones. In a discussion on rachitis in the London Patho- 
logical Society, reported in the London Lancet (18S8, ii. 1017), it was stated 
that in seventeen rachitic children with an average age of 4.72 years, the 
average circumference of the head was 21.22 inches, while in the same num- 
ber who were non-rachitic. and whose average age was 6.05 years, the aver- 



170 CONSTITUTIONAL DISEASES. 

age circumference was 19.95 inches. The retarded ossification is manifested 
not only in the open sutures, but also in the large size and patency of the 
fontanelles, which are not closed until long after the usual time. The ante- 
rior fontanelle in the healthy infant is closed at about the fifteenth or six- 
teenth month, but in the rachitic it remains membranous a longer time : in 
some cases it is still membranous as late as the third or fourth year. Since 
examination of the anterior fontanelle aids in determining whether or not 
rachitis be present, it should be borne in mind that in the normal state this 
space increases in size till the seventh month, when it is at its maximum, 
and that after the ninth month it becomes progressively smaller. Ossifica- 
tion in severe rachitis is retarded for a longer period than is stated above, for 
Gerhard relates a case in which the anterior fontanelle had not entirely closed 
at the ninth year. 

The shape of the rachitic head varies. In general, instead of its normal 
rounded form it approaches a square shape. Another type is sometimes 
observed in which there is no marked angularity, but in which the antero- 
posterior diameter is enlarged. In the square head the forehead projects, 
and both the frontal and parietal protuberances are unusually prominent. 
The sutures are depressed to a certain extent, as has already been mentioned, 
and the anterior, lateral, superior, and posterior surfaces are more flattened 
than in health. The undue prominence of the frontal and parietal eminences 
is largely due to the exaggerated proliferation of the periosteum and to the 
vascularity and infiltration underneath. Enlarged veins are seen ramifying 
in the scalp, which in marked rachitis supports a scanty growth of hair. 
The free perspiration from the scalp, and in some cases the activity of its 
sebaceous follicles, will be mentioned elsewhere. 

Craniotabes. — Thinning of the cranial bones in places, so that the brain 
lacked proper protection, had long been noticed in the examination of rachitic 
heads, but the injury that resulted to the infant was overlooked until pointed 
out by Elsasser. Craniotabes occurs for the most part in infants under the 
age of one year, and a large proportion are under eight months. Its occur- 
rence in the foetus, as shown by a case published in the New York Obstetrical 
Journal in 1870, and by Heitzmann's case, has already been alluded to. The 
factors in producing this thinning are rachitic softening of the bones and 
pressure from the brain within and from the pillow without. Consequently, 
the portions of the cranium in which the thinning is most pronounced are the 
posterior and lateral, the occipital bone and the posterior half of the parietal. 
If the infant lie in its crib chiefly on one side, on this side the craniotabes 
occurs, while those portions of the cranium which are not pressed upon 
exhibit no thinning or a less degree of it. The soft spots in the cranium 
are yielding when pressed upon, and in the cadaver they are seen to be trans- 
lucent when the bone is held to the light. There are in some instances simple 
depressions like erosions in the bone, a continuous but thin bony layer remain- 
ing. In other cases, such as have been particularly examined and studied by 
physicians, the bony absorption has been complete over areas of greater or 
less extent. On examining a child for craniotabes it should be borne in mind 
that the margins of the cranial bones, even when there is no thinning, but 
thickening from the cartilaginous proliferation, are flexible in the rachitic. 
The pressure must be made in a direction away from the sutures to ascertain 
whether craniotabes has occurred. The pressure should at first be made 
lightly and cautiously with the fingers, for if there be total absence, unless 
of very little extent, deep and forcible pressure might injure the brain, 
since so soft and delicate an organ, covered only by scalp and dura mater, 
badly tolerates pressure. If the first examination detect no soft place, the 
fingers may be pressed more firmly against the scalp, when, if the bone be 



RACHITIS. 



171 



much thinned, so that there is only a small layer of lime salts underneath, it 
will be found to yield. The sensation communicated to the fingers when 
there is an open space in the cranium, and the dura mater and scalp are in 



Fig. 24. 




Head of a rachitic child in the New York Infant Asylum. This child also had 
laryngismus stridulus. 

contact, has been likened to that experienced when pressing upon a fully-dis- 
tended bladder. At a meeting of the London Pathological Society, reported 
in the Lancet for November, 1880, Dr. Lees presented statistics to show that 
craniotabes is one of the lesions of inherited syphilis ; but whether it does 
sometimes result from inherited syphilis or not, the evidence that there is a 
cranial softening which is strictly rachitic, and which occurs in those who 
have not inherited syphilis, appears from reported observations to be con- 
clusive. 

Changes in the Vertehrse, etc. — The short bones which participate in the 
rachitic disease become softer and more yielding, and their cancelli are filled 
with a reddish pulpy substance. In many rachitic cases the vertebrae are but 
slightly involved, so that no deformity of the spinal column results ; but occa- 
sionally, when many bones are affected, the vertebrae and intervertebral carti- 
lages soften, and spinal curvatures result. The curvatures are due to the 
weight of the shoulders and head on the spinal column. They are, with some 
deviations, an exaggeration of those present in the normal state. Rachitic 
curvatures of the spinal column are therefore mainly antero-posterior, often 
with more or less lateral deflection. When there is much curvature the ver- 
tebrae become wedge-shaped, narrowed upon the concavity and thickened 
upon the convexity. The intervertebral cartilages are also more or less 
changed by the pressure, being thinned where the vertebrae approximate to 
each other on the concave aspect of the curvature, and of normal thickness 
or thicker than normal upon the convexity. The accompanying wood-cut 
exhibits the appearance and nature of rachitic spinal curvature continuing 
into adult life. Rachitis, having occurred at the usual age, resulted in the 
permanent deformity here illustrated. 

In extreme cases, fortunately rare, the functions of important organs may 
be seriously impaired by the curvature and consequent compression, as they 
are in Pott's disease. Thus, according to Miller, the aorta has been so 



172 



CONSTITUTIONAL DISEASES. 



Fig. 25. 




doubled upon itself as to materially diminish the flow of blood to the lower 
extremities, so that their nutrition was sensibly impaired. The effect of so 
great curvature upon the heart and lungs must ob- 
viously be detrimental. At first the spinal curva- 
tures disappear when the child reclines or is lifted 
by the axillae so as to raise the head and shoulders 
from the spine ; but when the deformity has con- 
tinued so long that the vertebrae and cartilages 
have become wedge-shaped, it remains for life or 
can only be rectified slowly and with difficulty by 
mechanical appliances. As seen in the wood-cut, 
the common curvature in the dorsal region is back- 
ward (kyphosis), while to compensate the patient 
instinctively carries the neck forward with the 
head thrown back, causing cervical lordosis, a sim- 
ilar anterior curvature being common in the lum- 
bar region. Lateral curvature (scoliosis) may or 
may not be present even when there is consider- 
able antero-posterior flexure. Scoliosis is some- 
times produced by the nurse in carrying the infant 
habitually over one arm. 

Changes in the Maxillse. — Fleischmann has 
investigated the changes which rachitis produces 
in the maxillary bones. Stunted growth of the 
facial bones, generally, has long been known, and 
has been remarked upon by various writers ; but, 
according to Fleischmann, other interesting changes 
occur in the jaw-bones which affect the direction 
and position of the teeth. According to this ob- 
server, the arched shape of the lower jaw becomes polygonal, and the direc- 
tion of its alveoli also changes, so that they incline inward. This devia- 
tion in the arch and in the alveolar border of the lower jaw, which begins 
in the region of the canine teeth, necessarily causes softening of the jaw. 
Commencing soon after, a change is observed in the upper jaw-bone from the 
zygomatic arch forward, so as to cause lengthening of this bone, changing 
the shape of the arch and the position of the teeth. The external incisors, 
instead of being in front, have a lateral position, and when the jaws are closed 
the superior incisors and molars overlap the corresponding teeth of the lower 
jaw in front and upon the sides — a condition opposite to that seen in the jaws 
of old people. Fleischmann attributes these changes in the lower jaw to the 
action of the masseter and the mylo-hyoid muscles, and perhaps the genio- 
glossus, and to pressure of the lip, the deficiency of earthy salts in the 
bone rendering it more easily acted on by the muscles. The change in the 
upper jaw-bone he attributes largely to lateral pressure of the zygomatic 
arches. 

Changes in the Ribs. — The ribs are easily affected in rachitis. The swell- 
ing of their anterior ends, where they unite with the costal cartilages, pro- 
ducing the ' ; rachitic rosary," has been already alluded to as one of the first 
and most conspicuous signs of rachitis. The costochondral articulations are 
enlarged in all directions, appearing as nodules under the skin. If at an 
autopsy an opportunity of inspecting the pleural surface of the articulation 
occur, the nodular prominence is seen to be even greater and more distinct 
than under the skin (Fig. 26). 

The deformity of the thorax, consequent upon softening of the ribs, is 
Commencing with the spine, the ribs extend nearly directly out- 



Rachitic spinal curvature in 
an adult (from a specimen 
in the Wood Museum, Belle- 
vue Hospital). 



RACHITIS. 



173 



ward : at the union of the dorsal and lateral portions they make a short curve 

Fig. 26. 




Rachitic child with characteristic deformity of head and ribs. (From a patient in the 
New York Foundling Hospital.) 

forward and then turn inward, also with a short curve, toward the sternum 
(Fig. 22). This abrupt bending of the ribs, which in their softened state has 

Fig. 27. 




Deformity of chest in rachitis. 



been caused by atmospheric pressure during respiration, produces a depres- 
sion in the thoracic wall at about the point where the ribs and their cartilages 



174 CONSTITUTIONAL DISEASES. 

unite. A groove extends on the antero-lateral aspect of the thorax from the 
second or third rib downward and a little outward. In some cases the costo- 
chondral articulations are in the line of greatest depression in the thoracic 
walls ; in other cases they are a little inside or outside of the deepest part of 
the groove. The transverse diameter, therefore, of the anterior half of the 
thorax is less than that in the normal rotund form of health. This neces- 
sarily diminishes the antero-lateral expansion of the lungs in inspiration and 
causes unusual prominence of the sternum. Hence the expressions " pigeon- 
breasted," " resemblance to the prow of a ship," etc. applied to this deformity. 
The presence of the heart renders the depression or groove less on the left 
side between the fourth and sixth ribs than on the opposite side, since this 
organ affords partial support to the chest-wall. That portion of the pericar- 
dial surface of the heart upon which the pressure is greatest becomes 
thickened and whitish from the rubbing or attrition. On the other hand, 
the depression on the right side below the sixth or seventh rib is, on 
account of the support given by the liver, less than on the left side. But 
on the left side, as well as on the right, the lower part of the thorax, that 
below the eight or ninth ribs, widens, being pressed outward and supported 
by the abdominal viscera. This gives rise to an antero-lateral furrow or 
groove near the base of the chest, sometimes designated Harrison's groove, 
the site of which is supposed to correspond with that of the insertion of 
the diaphragm. 

The ribs with their attached muscles are important agents in respiration, 
but their soft and yielding nature in the rachitic retards, and to a great 
extent prevents, the lateral expansion of the thorax which is necessary for 
normal and full inspiration. The action of the respiratory muscles and the 
pressure of the air from within descending along the air-passages is not suffi- 
cient to fully overcome the external atmospheric pressure in the absence of the 
proper resiliency of the ribs. Consequently with each inspiration we observe 
more or less sinking of the thorax on each side, just as when a moderate 
obstruction to the entrance of air exists in the larynx or trachea. As the 
ribs become firmer from the deposit of lime salts, respiration is more regular 
and normal. 

Changes in Bones of Upper Extremities. — Although swelling of the 
lower end of the radius is one of the earliest signs of rachitis, the bones of 
the upper extremities are less frequently curved and distorted than those 
of the lower extremities. The clavicle sometimes softens and bends, pro- 
ducing two curvatures — one backward near the scapula, and another, of larger 
radius, nearer the sternum, directed forward and a little upward. Careful 
examination shows, in some rachitic patients, thickening of the margins of 
the scapulae like that of the cranial bones. The humerus is occasionally 
bent, and usually at the insertion of the deltoid in consequence of the power- 
ful action of this muscle in raising and supporting the arm. The radius and 
ulna are bent outward and twisted. This deformity is attributed by Sir 
William Jenner to the fact that rickety children support themselves while in 
the sitting posture upon the palms of the hands pressed upon the floor or 
couch. Supporting the weight of the body in this manner not only, in his 
opinion, causes bending of the ulna and radius, but also aids in producing 
the deformities of the humerus and clavicle. 

Changes in the Bones of the Pelvis. — The deformities of the pelvic bones 
resulting from rachitic softening are very important in the female infant, 
since pelvic deformities during the procreative period are the common cause 
of tedious or instrumental labor and stillbirth. These deformities, which 
elongate some and contract other axes of the pelvis, necessarily occur when 
the rachitic child is in the erect position, since the pelvic bones support the 



RACHITIS. 



175 



weight of the trunk, head, and shoulders. A common deformity produced 
in this manner is the carrying forward of the promontory of the sacrum, 
which sustains the weight of the spine. There is, moreover, twofold pres- 
sure from below — that caused by the heads of the thigh-bones in standing, 



Fig. 28. 



Fig. 29. 



Fig. 30. 




Rachitic deformities of the pelvis (from specimens in Wood's Museum). 

and that exercised by the tuberosities of the ischia in sitting. Both these 
forms of pressure have a tendency to narrow the outlet of the pelvis. 
Hence the marriage of the female who has been rachitic in infancy may 
involve serious consequences. 

Many of the tedious instrumental labors in the families of the city poor, 
which severely tax the patience and endurance of young practitioners, are 
attributable to rickets in early life. 

Changes in the Bones of the Lower Extremities. — The curvature of the 
femur is usually forward or forward and outward. The neck of the femur 
sometimes bends by the weight of the body or by use of the legs, so that the 

Fig. 31. 




Rachitic deformities of the femur (Wood's Museum). 



angle which it forms with the shaft is changed. The accompanying wood-cuts 
show the rachitic bend of this bone in an adult, years after rachitis had ceased 
and when the bone had become consolidated by the new deposition of lime 
salts. (Figs. 31 and 32.) 



176 



CONSTITUTIONAL DISEASES. 



Fig. 33. 



Fig. 34. 



The curvature of the tibia and fibula varies in different cases. In those 
under the age of one year it is likely to be outward, so that the knees are 
separated from each other. In those old enough 
to stand, the weight of the body usually determines 
a forward bending of these bones. In one case 
in my practice an anterior curvature, so abrupt 
that an angle of about 70° was formed, existed 
about five inches above each ankle. This patient, 
although old enough to walk, almost constantly 
sat during the day with the feet extended beyond 
the sofa, so that the edge of the latter corresponded 
with the abrupt curvature or angle of the legs. It 
seemed that the weight of the feet, unsupported 
beyond the edge of the sofa, had caused these cur- 
vatures, especially as the case was one of very 
marked rachitic softening of the different bones. 

Still, tibial and fibular bending at this point 
has been noticed by different observers, who have 
attributed it to the weight of the body in walking. 
Various other curvatures besides those mentioned 
occur in the bones of the lower extremities, the di- 
rection in which the limbs bend being determined 
by the particular circumstance of the case. In 
mild cases of rickets most of the deformities de- 
scribed above may be lacking, but in typical cases 
certain of them stand out prominently, so as to be 
readily detected by one familiar with the disease. 
In all such cases the nature of the malady is ap- 
parent, for the changes that occur are not only 
conspicuous, but pathognomonic. 

Rachitis produces another important effect on 
the skeleton. Its growth is stunted, not only 
during the rachitic period, but subsequently, so that those who have been 
rachitic in childhood, unless very mildly, have less than the average stature 
in adult life. The stunted growth is apparent, though ample allowance be 
made for curvatures. The arrest of development is greater in some bones 
than in others. It is greatest in the bones of the face, pelvis, and lower 
extremities. As a rule, the older the child is when rachitis begins, the less 
is the skeleton affected and the less, consequently, is the deformity, 

Effect of Rachitis on Dentition. — As might be expected from the nature 
of rachitis, dentition suffers severely. The delay in dentition has been con- 
sidered elsewhere in this paper. Teeth which appear during the rachitic 
state are frail, deficient in enamel, and crumble readily. They decay and 
break before the usual time. If certain teeth have appeared before rachitis 
begins, several months elapse before others cut the gum. It is even said 
that a child who has rachitis severely for a lengthened period may never have 
a tooth, and may remain toothless for life ; but I have never observed such a 
case. Ordinarily, when the rachitic state ceases and the health is fully 
restored dentition goes on in the normal way. 

3. Anatomical Characters of the Stage of Reconstruction. — This stage 
will be better understood if we recollect what has occurred during the first and 
second stages. The very vascular periosteum is drawn tightly over the con- 
vexities, the pressure upon which diminishes the hyperasmia and the amount 
of exudation underneath. Over the concavities the periosteum is loose : it 
is hyperaemic with abundant new capillaries, the interspace between it and 




Rachitic deformities of the fe 
mur, tibia, and fibula (Wood's 
Museum). 



BACHITIS. 177 

the bone being filled with the exuded soft material having a gelatiniform 
appearance. The reparative process goes forward rapidly, the deposition of 
lime salts being more abundant upon the concave surfaces, where there has 
been free exudation with no compression of the capillaries, than elsewhere. 
The lime salts are deposited from the blood. Consequently, from the increased 
capillary circulation and hyperaemic state of the periosteum produced by 
rachitis, the earthy material is rapidly deposited wherever there is an open 
space under the periosteum and where the capillaries are in a state of enlarge- 
ment. Hence the reconstructed bone is thicker and firmer upon the concave 
aspect of the long bones than elsewhere, and thinnest upon the convex aspect, 
where the periosteum is more tense and its capillaries more or less com- 
pressed. 

Xormal ossification does riot at first take place during the reparative stage. 
The deposition of the earthy salts is designated by some writers as a petrifac- 
tion rather than a true bone-formation. Trousseau likens it to the formation 
of a callus upon a fracture. A deposition occurs of lime salts more compact 
than in ordinary bone. The term " eburnation " has been applied to this new 
osseous formation, and I have designated it osteo-sclerosis. It resembles, as 
regards its hardness and morphological appearance, the enamel of the tooth 
rather than true bone, the Haversian canals and lacunae being small and im- 
perfectly formed. Of course after complete recovery the subsequent form- 
ation of bone is normal. Recovery from rickets is gradual. Little by little 
the cartilaginous and periosteal proliferations cease, the hypereemia abates, 
and the various parts of the osseous system and the soft tissues resume their 
normal function and development. 

General Symptoms of Rachitis. — Preceding and accompanying rachitis 
symptoms may be present which are due to indigestion and intestinal catarrh, 
such as flatulence, unhealthy stools, and poor and capricious appetite. When 
rachitis begins the infant becomes fretful ; its sleep is frequently restless and 
disturbed, and it awakens often. It repels attempts to amuse it, and is 
apparently annoyed by them. Nurse and mother speak of it as a cross child. 
It perspires freely from the head and neck both when awake and when asleep, 
while its extremities and trunk are dry. Its pillow is wet with perspiration 
during sleep, and sweat-drops may be seen upon forehead and face. If the 
surface be dry, a little excitement or elevation of temperature causes perspira- 
tion to appear. The rachitic child does not well tolerate the bed-clothes, and 
it attempts to throw them off from its limbs, even in cool weather, lying ex- 
posed and causing considerable annoyance to the nurse, who strives to pre- 
vent its taking cold. Sometimes miliaria due to the moist state of the skin 
appears upon the face and neck. We have elsewhere stated that the sub- 
cutaneous veins that return blood from the head are large and the jugular 
veins full. Another symptom is soon observed, to wit : tenderness over a 
considerable part of the surface, perhaps largely due to the morbid state of 
the periosteum over so many bones, though it is also experienced when pres- 
sure is made upon soft parts, as the abdomen. The tenderness is probably the 
cause in part of the fretful disposition. The little patient appears to dread 
to be touched ; its flesh is sore ; it repels attempts to amuse it, and wishes to 
be quiet. Dangling it upon the arms, swinging it, or even walking with it. 
which delights the healthy child and elicits a smile or notes of glee, only 
adds to its discomfort. It is most at ease when left alone upon a soft cot or 
pillow, or, if it have craniotabes, when quietly held over the shoulder. Lan- 
guor, disinclination to use the limbs or to play, moderate thirst, with other 
symptoms referable to the digestive apparatus which are present in many 
cases, and which have already been described, are soon followed by changes 
in the skeleton that are perceptible to the sight and on palpation. The pulse 
12 



178 CONSTITUTIONAL DISEASES. 

and temperature in a large proportion of the ordinary chronic cases do not 
deviate from the healthy state, except that in some patients there is a 
moderate rise in temperature and acceleration of the pulse in the latter part 
of the day, indicative of a slight fever. 

A bruit de souffle of greater or less intensity, synchronous with the pulse, 
has frequently been heard in rachitic cases by applying the ear over the ante- 
rior fontanelle. Drs. Whitney and Fischer, New England physicians, first 
called attention to this murmur, believing it to be a sign of chronic hydro- 
cephalus. MM. Rilliet and Barthez heard it in cases of rachitis, and therefore 
concluded that the American physicians had confounded the two diseases. 
More recent observations have established the fact that this bruit has little 
diagnostic significance. It is heard whenever there is sufficient patency of 
the anterior fontanelle both in health and disease. It is conducted from the 
base of the brain through the brain-substance to the membranous covering 
of the fontanelle. Dr. Wirthgen heard the bruit in 22 of 52 infants, of 
whom all except 4 were in good health. I have auscultated the anterior fon- 
tanelle in 29 infants who were, with two exceptions, between the ages of 
three or thirty months. All were well or affected merely with trivial ail- 
ments which did not disturb the cerebral circulation. In most of them a 
murmur could be distinctly heard synchronous with the respiratory act, and 
in 15 of the 29 cases no other sound could be detected, while in the remain- 
ing 14 a bruit could be detected synchronous with the pulse. 

As might be expected, craniotabes gives rise to symptoms quite distinct 
from those of the general rachitic disease. It usually occurs during the first 
year of infancy, and most frequently prior to the tenth month. The brain at 
this age is soft and yielding, since it contains a large percentage of water. 
Unless handled with care at an autopsy, it is readily lacerated, and moderate 
pressure upon it is seen to disturb and move it a considerable distance from 
the point of contact. It will assist to a proper understanding of the symp- 
toms referable to the cerebro-spinal system to which the rachitic are liable, to 
recall to mind the fact, well known to surgeons, that slight depression of even 
a small portion of the skull is likely to produce grave consequences. It is 
not surprising, therefore, that craniotabes, when there is a space of consider- 
able size in the cranial arch destitute of bone, is attended by symptoms due to 
the mechanical effect of external pressure whenever a substance less yielding 
than the brain comes in contact with the unprotected part. 

Every rachitic child is fretful, but one with craniotabes is especially so if 
the open spaces, in which the lime salts are lacking or constitute a thin and 
yielding layer, are of considerable size. If the child lie upon the pillow in 
the position that is most natural for it, the unprotected portion of the brain 
may be so pressed upon by the weight of the head that it is uncomfortable 
and restless. It does not have quiet sleep because the cerebral circulation 
and functions are disturbed since the cranial arch no longer protects the brain 
from undue pressure. Carefully placed in an apparently comfortable position, 
it awakens often and frets until it is taken in the nurse's arms. Sometimes 
it instinctively seeks a position on the edge of the pillow, with its face down- 
ward, and it becomes more quiet when resting over the nurse's shoulder with 
no pressure or support upon the cranial arch. 

But if fretfulness, disturbed sleep, and the necessity of closer attention 
on the part of mother and nurse were the only ill effects of craniotabes, 
it would possess much less pathological significance than pertains to it. 
Pressure upon so delicate and important an organ as the brain involves 
risks and produces serious symptoms in proportion to its degree. Even a 
slight injury of the skull which causes depression, though it may be of 
trifling amount, will cause serious forms of nervous disorder. Rachitic 



RACHITIS. 179 

craniotabes sustains a causal relation in not a few instances to one of the 
most dangerous of the neuroses — to wit, laryngismus stridulus, or spasm of 
the glottis. Pressure on the cardiac and vaso-motor centres of the medulla 
in the rachitic infant, in whom reflex excitability is exaggerated, causes con- 
traction of the muscles that close the glottis. It is certain that a large 
proportion of those who suffer from laryngismus stridulus are rachitic, so 
that it is more common and severe where rachitis is prevalent, as in England, 
than where it is rare, as in the rural districts of America. It is not often 
the cause of death in America, and the fatal cases that do occur are, I 
think, nearly always in the cities, whereas in parts of Europe, where 
rachitis is much more common than with us, it is said to cause not a 
few deaths. 

Certain infants when in a state of excitement have what are termed 
" holding-breath spells." The face is flushed and breathing ceases for some 
seconds, after which respiration returns and is normal. The attacks are 
unimportant, but they appear to be the same in nature with the more severe 
and dangerous seizures of laryngismus stridulus. They have no pathological 
significance, excepting that they show the same neuropathic state as that in 
laryngismus, and that they may be precursors of it. 

Laryngismus stridulus, or glottic spasm, is usually preceded by more or 
less impairment of the general health and often by fretfulness, which is 
characteristic of the rachitic state ; but the attack occurs suddenly, without 
premonition, and is of short duration. It begins with an arrest of respiration, 
a true apncea, as if from paralysis of the respiratory centre in the medulla ; 
the lips may be livid, a pallor spreads over the face ; sometimes more or less 
rigidity of the limbs occurs, with carpo-pedal contractions. After a few 
seconds, a quarter or half minute, a long and deep but difficult inspiration 
through the narrow chink of the glottis follows, accompanied in many patients 
by a whistling or crowing sound, and the attack ends with perhaps a moment- 
ary appearance of bewilderment or dread on the child's face. Laryngismus 
stridulus, like eclampsia, does not have a uniform causation. In certain cases 
it is a reflex phenomenon due to an irritant in some part of the system, as in 
the intestines, but many observations establish the fact that rachitis is prob- 
ably its most common cause. A large proportion of the infants affected with 
it exhibit unmistakable rachitic signs ; and it has been held that the exposed 
state of the brain in craniotabes affords explanation of the symptom. But 
from observations which I have made and from those of other observers, like 
Senator, it is certain that laryngismus stridulus is common in the rachitic 
who do not have craniotabes, so there must be a causal relation in rachitis 
to spasm of the glottis independent of the cranial softening. 

Distinguished British observers, as Gee and Jenner, have noticed the fact 
that rachitic infants are especially liable to eclampsia. The immediate or 
exciting cause seems to be in many cases the severe catarrh of the respira- 
tory and digestive systems to which rachitic infants are especially liable. 
Indigestion, flatulence, and fermentative diarrhoea, common disorders of the 
rachitic, are perhaps, in some instances, the exciting causes of the eclampsia. 
Similar remarks may be made in reference to tetany, which, although it 
occurs in the adult, and is comparatively rare, appears to be more frequent 
in rachitic than in other children. 

Those physicians who attend in institutions in which children coming 
from tenement-houses are treated in a large city like New York have noticed 
the fact that the various tissues of the body, besides those that are con- 
spicuously affected in rachitis, are more liable to inflammatory diseases than 
are the same tissues in those who have sound constitutions. The frequency 
of the different forms of dermatitis, of nasal, post-nasal, faucial. and bronchial 



180 CONSTITUTIONAL DISEASES. 

catarrhs, and of gastrointestinal maladies, we must attribute to the fact that 
rachitis diminishes the resisting power to noxious agents in the various soft 
tissues, and renders them more liable to disease. 

If the deformity in the thoracic wall — to wit, the lateral depression of the 
ribs and anterior projection of the sternum — be great, we would naturally 
expect that the two important organs underneath, the heart and lungs, would 
receive some detriment. Upon the surface of the heart, at the point where it 
supports the softened ribs, a white patch is often found, due to thickening of 
the pericardium and proliferation of the endothelial cells, just as thickening 
of the skin in the palm of the hand occurs from friction and pressure upon 
that part. It is probable that in ordinary cases this pressure does not 
seriously impair the function of the heart, but it may increase the weakness 
of its movements in supervening asthenic diseases, which may occur during 
the rachitic period. The injury sustained by the lungs is greater and more 
apparent. If the lateral depression of the ribs be considerable, full inflation 
of the lungs does not occur in those parts where the depression is greatest. 
The semi-collapse of certain lobules is likely to occur, and even complete 
collapse of the distant thin edges of the lungs. The stress of respiration 
falls unequally upon different parts of the lung. The anterior portion, which 
ascends with the sternum as that is propelled forward, is more fully dilated 
than the lateral and posterior parts, and it may in consequence become 
emphysematous. If in this state of the thorax and lungs severe bronchitis 
or broncho-pneumonia occurs, the muco-pus, being expectorated with diffi- 
culty, clogs the tubes, produces dyspnoea, and imperils the safety of the child. 
Even in comparatively mild forms of inflammation the result may be unfavor- 
able, owing to the lack of full expansion in the lateral and depending portions 
of the lung — a condition required to expel the mucus. Severe bronchitis and 
broncho-pneumonia are the causes of death in not a few cases of rickets 
attended by marked deformity of the thorax. 

Rachitic Paralysis. — In not a few instances in the course of rachitis the 
use of the limbs is greatly impaired, so as to resemble paralysis, and be desig- 
nated by this name, though the term " paralysis " is probably a misnomer. 
Cases like the following, related by Dr. H. W. Berg in the New York Medical 

Record, which closely resemble paralysis, occasionally occur : J. S , aged 

two years and eight months, was admitted into the Orthopaedic Dispensary 
Sept. 23, 1885. The parents stated that the child had never walked or stood 
alone. The legs were wasted, apparently from disease ; the patellar reflex was 
good ; there seemed to be some rigidity of the muscles about the knee ; and 
the patient was admitted with the diagnosis of " spastic paralysis.'' A closer 
examination disclosed the fact that the disease was one of typical rachitis, 
and by the use of the proper diet, with iron and phosphorus the patient was 
able to walk in November, and in a few months was entirely cured. The 
British Medical Journal, Jan. 4, 1890, contains the account of a case of 
rickets discussed by the Edinburgh Medical Society, Dec. 4, 1889. The 
patient, a boy of three years, had the waddling gait and straddling pose of 
pseudo-hypertrophic paralysis. The rachitic nature of the malady was made 
apparent by the symptoms of the case and its history. I have recently in 
private practice observed two similar cases of pseudo-paralysis of the lower 
extremities from the same cause. 

Acute Rickets. — Occasionally rachitis occurs with the sudden develop- 
ment of severe symptoms, so that the term " acute " is applied to it. Dr. 
Fiirst relates such a case in the Jahrb. fiir Kinderh., Band xviii. p. 192 : The 
patient, aged two years and one month, had been largely fed upon starchy 
food, and at six months had dyspeptic symptoms and sweating. Dentition 
began in the thirteenth month, and ability to walk several months later. 






RACHITIS. 181 

Spasmodic croup and swelling of the epiphyses appeared at this time. At 
the above-mentioned age the child suddenly fell ill with acute febrile symptoms. 
It had an open anterior fontanelle, craniotabes, and a rachitic chest ; upper 
extremities free from pain and not swollen. The left femur and both tibiae 
showed diffuse cylindrical swelling. The appearance and feel of the limbs 
were suggestive of diffuse cellular infiltration proceeding from the periosteum 
in an attack of osteo-myelitis. The skin covering the limb was tightly drawn 
and of a reddish hue. In a few days the right forearm was affected, and soon 
after the right arm and left forearm, and the parts first attacked began to 
improve. In four weeks the fever and pain had abated, but swelling of the 
epiphyses and deformities of various bones continued. Cases like the above 
establish the fact that although rachitis is ordinarily a chronic disease, insidi- 
ous in its commencement, gradual and progressive in its development, occu- 
pying months, there is an acute form which is attended by more marked 
febrile movement and tenderness than occurs in the usual type, and in which 
the articular swelling appears more quickly. 

Treatment. — Hygiene. — We recall the recent statement of Prof. Henoch 
of Berlin that the spread of rachitis has been enormous in the cities of Cen- 
tral and Northern Europe. The poor of these cities, among whom this disease 
largely prevails, are emigrating in large numbers to the United States, but, as 
I have observed in the asylums and dispensaries of New York, the severest 
forms of imported rachitis come from Southern Europe (Italy). Evidently, 
as long as the influx of this class of foreigners continues, and the present 
insanitary conditions exist in our cities, causing rachitis in the native born, 
this will continue an important disease, impairing the health and vigor of 
coming generations. It is evident from the nature of rachitis that success in 
preventing it and in curing those who unfortunately exhibit its characteristic 
signs requires beyond anything else the employment of proper hygienic 
measures. The details of the hygienic requirements may seem prolix and 
tedious, but we cannot expect any marked diminution of rachitis until they 
are better known and heeded by the masses. 

The fact that inheritance is one of the recognized causes of rickets 
renders it very important that the parents be in good health. The mother 
especially should avoid all agencies or influences which impair the general 
health during the procreative period. She should, so far as possible, encour- 
age good appetite, take plain, easily-digested, and nutritious food, and lead a 
quiet, regular life, with sufficient out-door exercise to promote, so far as prac- 
ticable, a state of perfect health. Country residence, with quiet exercise in 
the open air, a diet consisting of fresh vegetables, meats, fresh and abundant 
milk, early retirement to bed and sufficient sleep, are much more conducive 
to the health of the mother and her child than are the excitement and irreg- 
ularities of city life. 

We have seen that there is sufficient clinical and experimental evidence 
that the common and predominating factor in causing rachitis is the use of a 
faulty diet, but general insanitary conditions are also potent agents. The 
foul air and noxious effluvia of the crowded tenement-house, so conducive to 
disease and fatal to infants in New York, should, if possible, be avoided. 
Even if poverty compels a residence in the small and dark apartments o\" a 
tenement-house, crowded by families, many of them entirely neglectful of 
sanitary measures, yet parents solicitous for the welfare of their children can 
do much to diminish the insanitary influences which surround them. Out- 
door air is everywhere available, and every child after the age of two or 
three months, unless suffering from acute disease, should in ordinary weather 
be in the open air one or more hours each day, as a means of improving its 
digestion and of producing a more vigorous state of the system. Any mother 



182 CONSTITUTIONAL DISEASES. 

or nurse capable of the care of a child should be able to employ such meas- 
ures as will prevent its taking cold while in the open air. 

The room occupied by a child, whether rachitic or not, should be at a 
uniform temperature of about 70° to 73° F., and it should receive the sun- 
light or the full daylight, which is often excluded by faulty construction. 
The undergarments worn during infancy and childhood should be of wool, 
thin and light during the summer, thicker and heavier in the winter. No 
intelligent mother need be told of the need of personal cleanliness of her 
child as a means of promoting its health as well as comfort. This is a hygienic 
measure, and we need not repeat that the more complete the sanitary condi- 
tions the less the liability to contract rachitis or any disease dependent on 
cachexia. Bathing of children should always be before the fire or in a warm 
room. The bath for an infant under the age of six months should be at about 
90°. As the age increases the temperature of the bath should be gradually 
reduced to 80° in the second year, to 75° in the third year, and to 70° sub- 
sequently. The bath should be short, only long enough to ensure cleanliness. 
For weakly infants it is sometimes best to dispense with the general bath, 
and employ the sponge instead. I see no advantage in the use of saline or 
medicated baths. After the bath the extremities should be warm, and to 
ensure a better peripheral circulation friction of the surface by warm flannel 
or otherwise, or the application of warmth to the limbs, is often useful. The 
extremities of a child should always be warm, for the normal warmth of the 
surface not only promotes nutrition of superficial parts, but it tends to pre- 
vent internal congestions and inflammations, to which the rachitic are espe- 
cially liable. A child that habitually has cool extremities cannot be at the 
maximum of health, and this is often the state of the poorly-fed and poorly- 
clad children of the tenement-houses. The measures to promote their normal 
circulation and warmth, such as exercise as far as practicable, artificial heat, 
exclusion of cold by woollen garments, friction of the limbs, either dry or by 
the use of mildly stimulating lotions, should be employed. But while the 
hygienic measures which we have detailed are important as a means of invig- 
orating the system and rendering it less liable to rachitis as well as other 
cachectic diseases, we repeat that the most common and potent cause of the 
malady which we are considering is a faulty diet, so that in the endeavor to 
prevent and to cure rachitis special attention must be given to the feeding. 

Clinical experience abundantly demonstrates the fact that in order to pro- 
mote healthy nutrition the food of the infant should be breast-milk until the 
age of ten or twelve months ; and subsequently, until childhood is well 
advanced, its food should consist largely of cow's milk, properly preserved 
and prepared. 

We need not state that human milk varies in its composition according 
to the health, diet, mode of life, and temperament of the individual who fur- 
nishes it. Many mothers possess the requisite moral traits to be good wet- 
nurses, and do all in their power for the welfare of their infants, but have an 
inadequate lacteal secretion. Many mothers, not only in the tenement-houses, 
but in the well-to-do class, are unable to furnish sufficient breast-milk, and 
their infants, unless they receive supplementary food, suffer from malnutri- 
tion and are liable to become rachitic. I have seen during the last year 
infants wet-nursed by their mothers, fretful, wasted, and at the verge of starv- 
ation, applied every half hour to the breast during the hours of wakefulness. 
Mothers, deprived of the needed sleep and sacrificing their own health in the 
constant endeavor to provide for the wants of their infants, usually have 
insufficient milk, as in the cases alluded to. Under such circumstances a 
medicine designated nutrolactis, which consists largely of the Galega offici- 
nalis, has been employed in the New York Infant Asylum with apparent bene- 



RACHITIS. 183 

fit as a stimulator of the lacteal secretion. But if suckling by the mother 
continue inadequate and her infant be under the age of six months, a wet- 
nurse should be employed. If this be impossible, supplementary feeding 
will be needed. We refer the reader to the article on the artificial feeding 
of infants treated of in the first part of this book. 

The prevention and the cure of rachitis require strict enforcement of the 
details of hygiene. Hence the facts detailed in the foregoing pages relating 
to the mode of life and diet of children should be observed in order to pre- 
vent cachexia and promote a healthy growth. 

Medicinal Treatment. — Medicines which aid the digestion and assimilation 
of properly-selected foods are sometimes useful. Irritability of the stomach, 
imperfectly-digested stools, flatulence, colicky pains, etc. indicate faulty diges- 
tion, which may be improved by pepsin given with each feeding. Tonic reme- 
dies designed to improve the appetite and digestion, of a kind suitable for the 
age and condition of the patient, are often useful. In anaemia one of the 
readily-assimilated preparations of iron should be given. The complications 
which are so common require special management. The laryngismus stridu- 
lus, eclampsia, and tetany should be promptly treated. 

The bronchial catarrh to which rachitic infants are liable may be best 
treated by remedies like the following : 

R • Ammonii chloridi, £j ; 

Syr. tolutan., fjij. — Misce. 

Sig. Dose fifteen drops every hour or two hours for an infant of six to ten months. 

R. Ammonii chloridi, 

Ferri et ammonii citratis, ad. £ss. ; 
Syrupi, fgj ; 

A quae, f§ iij . — Misce. 

Sig. Give one teaspoonful every two to four hours to a child of one year. 

Some of the rachitic cases with protracted bronchial catarrh, especially 
those which also exhibit scrofulous symptoms, may be most relieved by the 
syrup of the iodide of iron and cod-liver oil administered three times daily, 
with the inhalation of moist air containing turpentine vapor. 

In the protracted intestinal catarrh of rachitic infants I have observed the 
best results, so far as medicine is concerned, from the following prescription : 

R. Subnitrate of bismuth, ^ij-iij ; 

Elix. of digestive ferments or essence of pepsin, f^j ; 
Distilled water, f§iij. — Misce. 

Sig. Shake bottle ; give half to one teaspoonful, according to the age, every two 
hours. 

But a remedy is needed which will act promptly in the cure of rachitis so 
as to prevent the evil consequences which its continuance is sure to produce. 
It is the opinion of many of the best clinical observers who have had ample 
experience that this has been discovered in the daily use of minute doses oi' 
phosphorus. 

Wegner fed young and growing animals (rabbits and fowls) for months 
with small, non-poisonous, and easily-assimilated doses of phosphorus, with 
the result, he believes, of expediting ossification and producing firmer bone. 
He states that under the influence of phosphorus the large marrow spaces 
diminish, by the formation of true bone, to the size of the Haversian canals 
in normal bone. According to Wegner, the administration of finely-divided, 
non-poisonous doses of phosphorus for a prolonged period to older fowls pro- 
duced to a considerable extent the conversion of cancellous into compact bone 



184 CONSTITUTIONAL DISEASES. 

of normal chemical composition. Kassowitz has recently promulgated his views 
at some length on the pathology and treatment of rachitis. He states that the 
lime salts are not needed, since the ordinary food contains sufficient lime ; nor 
should the farinaceous foods be restricted. He adds that phosphorus in small 
doses restricts the formation of vessels in the growing bones of small animals. 
Hence it is useful as a means of overcoming the hyperemia, Kassowitz 
administers about y-|-g of a grain in a teaspoonful of cod-liver oil, the dose, 
of course, varying according to the age of the infant. The distinguished 
psediatrist of Vienna, Dr. Widerhofer, says of this remedy that its employ- 
ment " impresses him with the belief that it is not without benefit in the 
second year of life and upward." He thinks that it may be useful in the 
hardening of long bones, but he has not been able to obtain good results in 
craniotabes. Starker gives an analysis of 23 rachitic cases treated by Prof. 
Thomas of Freiberg in his clinic. He used the following formula : 

R. Phosphori, 1 centigramme (about \ grain); 

01. morrhuse, 100 grammes (about 3 ounces). — Misce. 

A coffee-spoonful was administered twice daily, but variations in the dose 
according to the age are not stated in the report, the patients being between 
the ages of a few months and four years. Improvement in the general con- 
dition in 18 cases ; in the cranial development in 15 cases; in dentition in 14 
cases ; in the shapes of the epiphyses in 21 cases ; in locomotion in 17 cases ; 
but strict attention was bestowed upon the hygiene, and especially upon the 
diet. Soltmann states that good results occurred from the use of phosphorus 
in 70 cases which he had under observation, and in no instance were unfavor- 
able results noticed. W. Meyer obtained similar results in 42 cases. He 
regards phosphorus as a specific for rachitis. When properly given it always, 
says he, produces positive results. Petersen has treated 200 cases with phos- 
phorus, and regards it as a specific. Sigel concludes, from the observation 
of 40 cases in private practice, that constitutional treatment is of the greatest 
importance, but instead of the administration of iron, lime, etc., phosphorus 
should be prescribed. Unruh also made many observations in the treatment 
of rachitic cases by phosphorus in the Dresden Hospital in 1885 and 1886, 
and considers it more efficacious than other remedies. 

Toplitz of Breslau treated 518 cases with phosphorus combined with cod- 
liver oil. No ill effects were observed, and in all the cases improvement 
occurred in the general condition. Of 208 cases of craniotabes, 176 were 
cured in eight weeks. In 58 cases of laryngismus stridulus the attacks 
ceased in eight to fourteen days, after having continued for months under 
other forms of treatment. Dentition was also promoted. 

In America, Dr. A. Jacobi, who has had a large clinical experience, also 
highly recommends phosphorus in the treatment of rachitis. The dose should 
be small, even minute, not more than ^io to yi-g- of a grain, according to the 
age, three times daily. 

As regards my own observations, I am not able to express a positive 
opinion as to the value of the phosphorus treatment, for reasons which I 
think also apply to many of the cases embraced in the favorable statistics 
of the distinguished observers mentioned above — to wit, the simultaneous use 
of cod-liver oil and improvement in the diet and general hygiene. 

The following prescriptions may be employed — first, the oleum phospho- 
ratum, made according to the following formula : 

R. Phosphorus, 1 part. 

Ether, 9 parts. 

Almond oil, 90 " — Misce. 

i 






RACHITIS. 185 

Or. secondly, the following, known as Thompson's mixture : 

R. Phosphori, gr. j. 

Alcoholis (absolut.), tt\, cccl. 

Spts. menth. piperit., tt^x. 

Glycerini, f^ij.— Misce. 

Sig. Six drops, increased to ten, three times daily, to a child of two or four years. 
Ten minims contain T ^ of a grain, and thirteen minims contain jfa of a 
grain. 

Phosphorus should, I think, be given after the meals, in order to prevent 
irritation of the stomach. 

Dr. H. H. Purdy, physician to the large class of children's diseases in the 
Out-door Department at Bellevue, has preserved statistics of the treatment 
of rachitis during the last year. The cases which furnish the statistics num- 
bered about 80, and he gives a resume of the results of treatment as follows : 
•• Some were given cod-liver oil alone, some, cod-liver oil with phosphorus, 
and others, phosphorus alone, and of course all the mothers were given 
instruction in feeding and hygiene. Those infants that received only phos- 
phorus were the slowest to improve. Indeed, in several cases this method of 
treatment was abandoned because of the absence of the signs of improvement. 
The group treated with cod-liver oil did the best. In fact, all of the infants 
that could tolerate the oil apparently derived benefit from it. The group that 
were given cod-liver oil with phosphorus did very well, but seemingly no better 
than those that were given only cod-liver oil. The preparation that seems to 
be most beneficial is one that is used at the Church Hospital and Dispensary. 
It is an emulsion of cod-liver oil made with the yolk of eggs. The formula 
for the emulsion is 

R. Yolks of ten eggs, 

Cod-liver oil, Oij. 

Syrup of wild cherry, Oj. 

Sherry wine, Oj. — Misce. 

Sig. One or more teaspoonfuls administered three or more times daily." 

In my opinion, the treatment by phosphorus is still tentative, notwith- 
standing its recommendation by so many distinguished physicians ; and the 
old remedies, cod-liver oil and iron, should not be abandoned, although trial 
may be made of phosphorus at the same time. 

Care should be taken to prevent deformities while the bones are soft and 
yielding. The patient should not be encouraged to stand or use the limbs 
until they become firmer. He should lie upon a soft and even mattress. Uni- 
form support of body and limbs is requisite in order to prevent curvature. 
In craniotabes the pillows should be soft, and care should be taken that the 
yielding parts of the cranium be not unduly pressed upon. Profuse per- 
spiration may be relieved by sponging with vinegar and water. The patient 
may be bathed in water a little cooler than the body, and rock salt may be 
added to the bath. 

The attacks of laryngismus stridulus, eclampsia, and tetany which so 
frequently complicate rachitis should be promptly treated by the remedies 
which are appropriate when they occur under other circumstances. Consti- 
pation may be treated by enemata of glycerin and water if not relieved by 
change of diet. 

The surgical treatment of rachitic deformities is sometimes important, but 
Prof. Ogston of the University of Aberdeen and other surgeons who have 
given special attention to this subject state that in young patients these 
deformities frequently diminish during growth, so as to cause little incon- 
venience in adult life. The measures employed by surgeons in order to cure 
or minimize the deformities are treated of in another section. 



186 



CONSTITUTIONAL DISEASES. 



CHAPTER II. 



SCKOFULA. 



The term scrofula (scrofa, a pig, from the resemblance which the enlarged 
cervical glands of a scrofulous individual cause to a swine's neck) is applied 
to a diathesis which is characterized by increased vulnerability of the tissues. 
The nutritive process of the tissues is readily disturbed even by trifling irri- 
tants or agencies in those who have this diathesis, and therefore the scrofulous 
are prone to inflammations of various parts. Inflammations which can prop- 
erly be considered as dependent upon this diathesis or as occurring under its 
influence are for the most part subacute or chronic, and they diiFer from 
ordinary inflammations in the fact of a greater cell-formation and greater 
liability to cheesy degeneration of inflammatory products, so that return to 
the healthy state by absorption is slow or impossible. Moreover, this diath- 
esis, while it gives rise to certain inflammations which do not occur or are 
rare in other states of the system, and which all physicians at once recognize 
as scrofulous, often modifies those common inflammations to which all per- 
sons, whether scrofulous or non-scrofulous, are liable, as coryza and bron- 
chitis, rendering them more protracted and less amenable to ordinary treat- 
ment. 

Scrofula is a disease chiefly of infancy and childhood. Manhood, espe- 

Fig. 35. 




cially the first years of it, is not entirely exempt, but scrofulous manifesta- 
tions after the age of twenty years are feeble and infrequent, disappearing 



SCROFULA. 187 

entirely as the individual advances toward middle life. The diathesis is most 
active prior to the age of ten years. 

Causes. — Scrofula is congenital or acquired. Parents who had scrofulous 
symptoms in early life or who are in a state of decided cachexia, as from can- 
cer, syphilis, intermittent fever, or tuberculosis, are likely to beget scrofulous 
children. Insufficient nourishment of the mother during a considerable part 
of her gestation, and advanced age, and therefore feebleness, of the father, 
are occasional causes. Near blood-relationship of the parents is also a recog- 
nized cause, and to this has been attributed the scrofula of royal families. 
Children whose father and mother are first cousins are, according to my 
observations, likely to be scrofulous. 

Again, those born with sound constitutions may acquire scrofula through 
antihygienic influences in the first years of life. Among the poor of New 
York we often observe one child in a family who presents scrofulous symp- 
toms, while the rest of the children are well, and in many cases we are able 
to trace back the diathesis to some depressing cause or causes which were 
sufficient to effect the peculiar change in the molecular condition of the tissues 
which constitutes this disease. Obviously, the causes of acquired scrofula are 
quite numerous. In the infant it is sometimes produced by insufficiency or 
poor quality of the breast-milk, or the use of artificial food during the period 
when breast-milk is required. Too protracted nursing at the breast also, espe- 
cially if artificial food be almost wholly withheld, may cause it ; as may also, 
in those who have been weaned, the continued use of a diet which is deficient 
in nutritive properties. 

Residence in damp, dark, and filthy apartments or streets may also pro- 
duce it. Hence one reason of its frequent occurrence among the city poor. 
Residence in a small, crowded, and imperfectly ventilated apartment has been 
known to cause it, even with personal cleanliness and a diet sufficiently 
nutritive. 

Scrofula may also be caused, in those previously robust and of sound con- 
stitution, by disease of an exhausting nature. The eruptive fevers, as small- 
pox, measles, and scarlet fever, if severe, occasionally produce this result, or 
they render active the diathesis which had hitherto been latent. In this city, 
where chronic entero-colitis of infancy is common, I have sometimes been able 
to trace the diathesis to the cachectic state and the impaired nutrition which 
it causes. 

The theory has recently been promulgated that scrofula has a specific 
principle, and that this is a modified form of the tubercle bacillus. This 
theory receives some support from the fact that scrofulous glands sometimes 
contain the tubercle bacillus, and scrofula in many instances precedes tuber- 
culosis. Van Merris considers the scrofulous inflammation as a local tubercu- 
losis, and Grrancher describes scrofula as a local curable tuberculosis. On the 
other hand, Dr. Jacobi regards the tubercle bacillus in a scrofulous disease as 
an " accidental invasion,' 1 and Lartigues calls attention to the fact that the 
tubercle bacillus cannot be discovered in most instances in the lesions of 
scrofula. Alexander also states that wherever we can trace the cause of 
scrofula, it seems to be distinct from any probable microbic agency (Annual 
of the Univer. Med. JSci., vol. iv., 1889). Noeldechen states that the close 
relationship of tuberculosis to scrofula arises from the fact that scrofulous 
ailments afford the most favorable soil for the development of the tubercle 
bacillus (Deutsche med. Zeit., 1887). Rabl also mentions the fact that the 
tubercle bacillus is often not present in scrofulous glands. He tabulates 
1000 cases of scrofula, as regards their causation, as follows : 79 had scrofu- 
lous parents, 446 had tuberculous parents, 356 lived in damp dwellings. 25 
were subjected to other bad hygienic surroundings, 69 could be ascribed to 



188 CONSTITUTIONAL DISEASES. 

acute infectious diseases, 14 to vaccination, 7 to decrepitude, and 4 to con- 
sanguinity of parents ( Wien. med. Zeit., 1887). 

Scrofula, as we have seen, results from a variety of depressing agencies 
affecting the system in different ways, with the general result of impairing its 
vigor and lowering its tone. The theory seems improbable that these many 
and distinct agencies cause the phenomena of scrofula through the action of 
a microbe peculiar to this disease. 

The primary scrofulous ailments by which the diathesis is manifested 
occur for the most part upon one of the free surfaces — namely, upon some 
part of the skin or mucous membrane. Certain writers attribute this to the 
fact that these parts are most exposed to the action of noxious agencies. 
The lymphatics lying in the inflamed area take up the altered lymph and 
carry it to the adjacent lymphatic glands, which become irritated and un- 
dergo hyperplasia, and perhaps ultimately suppuration. This is, in a large 
proportion of cases, the beginning of scrofulous ailments. Nevertheless, in 
not a few instances the first manifestations are in deep-seated and covered 
parts, as when scrofulous periostitis or osteitis occurs without any peripheral 
lesion. 

Rabl expresses the opinion that in certain cases scrofula results from 
syphilis in the parent or grandparent. He believes that syphilis in the parent 
causes scrofula in the child by diminishing the power of resistance to the 
causes which produce the latter affection. He thinks that in this manner 
parental syphilis gives rise in some children to symptoms identical with those 
of scrofula, while in other children it gives rise to syphilitic symptoms. The 
author's observations in this particular correspond with those of Rabl. 

Anatomical Characters. — There are no ascertained anatomical changes 
in the blood which are peculiar to scrofula. As long as the appetite and gen- 
eral health remain good and the local affections have not occurred, the com- 
position of this fluid is, so far as known, unaltered. In the cachexia which is 
present when the general health is impaired the blood becomes impoverished, 
the red corpuscles lose a portion of their coloring matter, and the watery ele- 
ment predominates. 

The question arises whether the glandular hyperplasia of scrofula pro- 
duces an excess of white corpuscles in the blood. Virchow says : " During 
the progress of an attack of scrofula, in which, if the disease run a somewhat 
unfavorable course, the glands are destroyed by ulceration or cheesy thicken- 
ing, calcification, etc., an increased introduction of corpuscles into the blood 
can only take place as long as the irritated gland is still, in some degree, 
capable of performing its functions or still continues to exist ; as soon, how- 
ever, as the glands are withered or destroyed the formation of lymph-cells 
likewise ceases, and with it the leucocytosis. In all cases, on the other hand, 
in which a more acute form of disturbance prevails, connected with inflamma- 
tory tumefaction of the gland, an increase of the colorless corpuscles always 
takes place in the blood." (CeHid. Pathol). Although the glandular hyper- 
plasia occurring in scrofula increases the number of white corpuscles in the 
blood, scrofula cannot be regarded as sustaining any causal relation to that 
great and constant increase of white corpuscles which characterizes the disease 
leukaemia ; for this disease, as remarked by Niemeyer, does not occur in child- 
hood, when the scrofulous diathesis is active, but in manhood, when it has 
ceased to exist or has become latent. 

Strumous inflammations of the cutaneous and mucous surfaces, which we 
have seen are the initial lesions in a large proportion of scrofulous cases, do 
not present any peculiar anatomical elements. Some of them are attended 
by an abundant formation of cells and by dense infiltration of the inflamed 
tissues ; but inflammations which do not depend on the strumous diathesis 



SCROFULA. 189 

have the same anatomical elements. The most marked differences between 
the strumous and non-strumous inflammations are found in their origin, amount 
of cell-formation and inflammatory exudate, and duration. 

The swelling of the lymphatic glands which is so common in the neigh- 
borhood of scrofulous inflammations, and is produced by the lodgement in the 
glands of irritating or noxious products of the inflammation taken up by the 
lymphatics and conveyed to the glands, is due to hyperplasia of the lymph- 
cells, with comparatively little or no increase of the stroma. Thus, hyper- 
plasia of the cervical glands is common, resulting from eczema of the scalp 
or face, or from otitis or any of the forms of stomatitis ; and so pharyngitis 
often gives rise to hyperplasia of the tonsils, which are lymphatic glands. 
The scrofulous nature of the glandular enlargement is apparent from the fact 
that it continues long after the primary inflammation which gave rise to it 
has abated. Lymphatic glands sometimes enlarge in those who are not scrofu- 
lous, but the tumefaction is commonly less in degree, and in most instances it 
soon abates when the exciting cause is removed. 

The glands which commonly undergo scrofulous enlargement are the cer- 
vical, inguinal, bronchial, and mesenteric ; but in those who are decidedly 
scrofulous the glands in the vicinity of any protracted inflammation are very 
prone to hyperplasia. Thus I have seen enlarged and cheesy glands in the 
vicinity of scrofulous osteitis or periostitis. 

Under favorable circumstances the glandular enlargement abates after a 
short time by liquefaction and absorption of the redundant cells. But the 
products of hyperplastic or inflammatory action in the scrofulous individual 
are very liable to undergo cheesy degeneration, and the close causal relation of 
this cheesy substance with tubercles is now admitted. If resolution does not 
soon occur in a gland, it begins to undergo cheesy degeneration. It becomes 
firm and inelastic, its nutrient vessels narrowed and compressed, so that cir- 
culation through it ceases, and its cells, losing their liquid and vitality, shrivel 
away. This necrobiotic process appears in points in the gland which enlarge 
and unite, till finally the whole gland becomes a dead mass, with shrivelled 
elements of a whitish appearance, like cheese, the resemblance to which has 
suggested the name by which the degeneration is known. 

In certain patients cheesy glands act as an irritant like inorganic matter, 
producing suppurative inflammation, and their subsequent history is that of 
an abscess. Purulent matter mixed with the cheesy debris escapes by ulcera- 
tion upon the nearest surface, and scrofulous ulcers result which slowly heal, 
leaving permanent cicatrices ; calcification of a cheesy gland occurs in excep- 
tional instances. 

The cervical lymphatic glands in the scrofulous child, having undergone 
hyperplasia of their cellular elements, not infrequently continue painless and 
indolent for a considerable time, producing, according to their size, an unsightly 
appearance without undergoing cheesy degeneration. Finally, one or more 
become inflamed, and the broken-down gland substance softens and is expelled, 
mixed with pus, through an ulcerated opening in the skin. 

In order to complete the description of the anatomical character of scrofula, 
it would be necessary to describe the various inflammations to which the diath- 
esis gives rise. Those which are most common and important occur in the 
skin, mucous membrane, connective tissue, the joints, the bones with their 
periosteal covering, and the eye and ear. Eczema and coryza are also very 
common scrofulous ailments. Phlyctenular keratitis with great intolerance 
of light, otitis externa, causing protracted otorrheea, or media and interna, 
causing deep-seated pain, with impairment or loss of hearing, offensive puru- 
lent discharge, and, in the gravest cases, caries of the mastoid cells or caries 
extending along the petrous portion of the temporal bone even to the brain. 



190 



CONSTITUTIONAL DISEASES. 



causing meningitis and death, are not uncommon manifestations of scrofula 
in the families of the city poor. Strumous cellulitis, occurring independently 
of the glandular affection and quickly ending in suppuration, is also common. 
The term cold is applied to the abscess when the local symptoms are slight 
and there is but little heat of the parts. In young children the common seat 
of these abscesses is directly under the skin, so that if subcutaneous cellulitis 
running into an abscess occur in a young child, he probably has the strumous 
diathesis. 

The osseous system is very prone to inflammation in the scrofulous. Peri- 
ostitis, osteitis, and arthritis, rare in those with healthy constitutions, are 
common in the scrofulous, in whom they result even from very slight injuries, 
and sometimes without the recollection of an injury, and apparently from the 
direct influence of the diathesis. These inflammations are more common in 
the lower extremities than in the upper. Periostitis often occurs in scrofulous 
children without osteitis when its usual seat is upon the shafts of the long 
bones, and it also accompanies inflammations of the bone, as pleurisy accom- 
panies pneumonia. The osseous inflammations of strumous patients are of two 
kinds : first, the destructive, producing caries with suppuration or necrosis ; 
and secondly, the so-called fungous, in which there is proliferation of tissue, 
as in white swelling. Often both these processes coexist, granulations and 
new tissue springing up while the carious or necrotic process is extending. 

Dactylitis is in most instances, when occurring in young infants, a syphil- 
itic affection, but in children of one year or more, in whom no marked syphilitic 
symptoms have previously occurred, it originates from the strumous cachexia, 

Fig. 36. 




as in the following case : Charles R , aged twenty months, was admitted 

into the New York Infant Asylum in 1876. He had always been pallid and 
had a strumous aspect. A physician acquainted with his parentage states 
positively that he is free from syphilitic taint, but when a few months old 
he had a mild form of coryza, which gradually abated under antistrumous 






SCROFULA. 191 

treatment. At the age of five months he had purpura haemorrhagiea of a 
severe form, but apparently not accompanied by hemorrhage from any of the 
mucous surfaces. The patches of extravasated blood were quite numerous 
and large over the trunk and limbs, and it was nearly three months before 
they entirely disappeared. A few months subsequently he began to have 
offensive otorrhoea on one side, which did not entirely cease. In December, 
1S76, at the age of eighteen months, well-marked dactylitis was first observed, 
involving the first phalanx of the left middle finger. The swelling was some- 
what tender, and the skin which covered it had a slightly reddish or pinkish 
tinge, indicating the inflammatory nature of the malady. Neither joint at the 
extremity of the phalanx was involved, so that the movements were unim- 
paired. The dactylitis increased somewhat after it was first discovered, and 
then began to decline under treatment with cod-liver oil and syrup of iodide 
of iron. The accompanying woodcut represents the outlines, obtained by 
tracing the hand of the infant when pressed on paper. 

Symptoms. — The scrofulous diathesis is exhibited by certain physical 
signs which are present in infancy, but are more manifest in childhood. In 
one class of strumous children they are as follows : Form tall and slender ; 
quickness of movement and perception ; intelligence good ; skin thin and 
semi-transparent, through which the superficial veins are distinctly seen; 
features delicate ; cheeks habitually pallid or florid, and flushed by slight 
excitement ; eyes bright, with bluish conjunctiva ; muscles and bones slender 
in proportion to their length. Those children who present these peculiarities 
are said to have the erethitic form of the diathesis. 

Others have what has been designated the torpid scrofulous habit, which 
is characterized by softness and flabbiness of the flesh, distended abdomen, 
large head, broad face, slow, languid movements, and an over-production 
of fat in the subcutaneous connective tissue in certain situations, especially 
the nose and upper lip. Though typical cases can be readily referred to one 
or the other of these forms, there are many which are intermediate. 

One of the earliest of scrofulous manifestations is subcutaneous cellulitis, 
alluded to above, giving rise to abscesses, commonly not large, with little sur- 
rounding induration, little pain, tenderness, and heat, and slow in discharging ; 
in a word, indolent. The most frequent seat of these abscesses is upon the 
extremities, but they may occur upon the scalp or elsewhere. They gradu- 
ally heal when the pus escapes, their site being indicated for a considerable 
time by the depression and reddish discoloration of the skin. Ordinarily, 
these abscesses do no harm apart from the reduction of the general health 
which they effect, but, when occurring in localities where the connective 
tissue lies upon the periosteum, as upon the fingers, periostitis may result, 
with destruction of the surface of the bone. Again, thrombi may occur in 
the vessels of the inflamed part, giving rise to emboli, embolismal pneumonia, 
and death. Specimens from such a case were presented by me to the New 
York Pathological Society in 1868. 

The scrofulous affections of the skin often also occur at an early age, even 
before dentition. They are more frequent in infancy than in childhood. The 
most common are eczema and impetigo, and, of rare occurrence, ecthyma and 
lupus. But all these may occur in those who are not strumous or who do 
not present the characteristics of the strumous diathesis. 

Scrofulous affections of the mucous surfaces are scarcely less frequent 
than those of the skin. They present the ordinary features of mucous 
inflammations of a subacute and chronic character. 

Sometimes they occur without obvious exciting cause; in other cases 
there is a cause of this kind, such as exposure to cold : but the inflamma- 
tion, once established, continues on account of the diathesis. It is often 



192 CONSTITUTIONAL DISEASES. 

doubtful whether inflammations in strumous subjects be of such a character 
that it is proper to designate them strumous, especially if they occur upon 
such surfaces as are frequently the seat of ordinary inflammation. If the 
child have heretofore presented symptoms of scrofula, if the inflammation 
be subacute, and there be no apparent cause to originate or sustain it apart 
from the diathesis, it is probably of a strumous character. The diagnosis 
is rendered more certain by observing the effect of antistrumous remedies. 
The most frequent of these scrofulous inflammations of mucous surfaces 
are coryza, tracheo-bronchitis, and conjunctivitis. More rarely, stomatitis, 
pharyngitis, vaginitis, and, according to some, entero-colitis, are of a stru- 
mous character. Coryza gives rise to snuffling respiration, the formation 
of crusts around and within the nares, and excoriation of the upper lip. 
The tracheo-bronchitis is attended by thickening of the mucous membrane, 
increased production of mucous and epithelial cells, and a loud tracheal rale 
accompanying each inspiration. 

Strumous inflammation of the mucous membrane of the trachea and 
bronchial tubes is a not very infrequent disease in this city. It sometimes 
originates in a simple inflammation from cold or the tracheo-bronchitis of 
measles or pertussis, and it may continue, with its rales, cough, and scanty 
expectoration, for months, unless relieved by a proper course of treatment. 

Among the most common of the strumous affections are inflammation of 
the eyelid, designated psorophthalmia, and that of the eye itself. The 
former is characterized by redness and thickening of the lids, detachment of 
the eyelashes, and inflammation and altered secretion of the " Meibomian 
glands ;" the latter — to wit, strumous ophthalmia — by pain, lachrymation, 
photophobia, and a moderate degree of hypersemia of the affected organ. 
One of the most common serious results of strumous conjunctivitis and 
keratitis is the formation of phlyctenules and ulcers on the margin of the 
conjunctiva and upon the cornea, fed by newly-formed vessels. If not con- 
trolled by proper treatment they may result in opacities more or less perma- 
nent, or possibly, worse still, in perforation, with its consequent ill effects. 

Inflammations of the external and middle ear have their origin very gen- 
erally in the strumous diathesis. Occasionally there is an exciting cause of 
the otitis, as an injury or severe constitutional disease, like scarlet fever. 
Protracted otitis, whether external or internal, and especially that form of 
it which leads to ulceration, destruction of the ossicles, and caries of the 
petrous portion of the temporal bone, it is proper in a large proportion of 
cases to regard and treat as strumous. 

The stubbornness and frequent disastrous consequences of scrofulous 
inflammation of the bones are well known. Nearly every bone, as well as its 
periosteum, is liable to this form of inflammation, but some are more fre- 
quently affected than others. Inflammation of the bone may terminate by 
resolution, by the formation of an abscess, or (and frequently) by carious or 
necrotic destruction of the bone itself. Necrosis most frequently occurs in 
the shafts of the long bones ; caries in the spongy extremities of these bones 
and in the spongy portions of the short bones. If abscesses form, the pus 
may finally escape from the system by a tedious ulcerative process, or, 
retained, may undergo cheesy degeneration. Scrofulous arthritis, if early 
detected and properly treated, may resolve, leaving no ill effect ; if other- 
wise, suppuration, ulceration, cartilaginous and osseous, and ankylosis often 
occur. 

Scrofulous children are perhaps no more liable to inflammation of the 
internal organs than other children, but the inflammatory products are more 
liable to cheesy degeneration, and the prognosis is therefore less favorable. 
The most frequent of these inflammations and the one of chief interest is 



SCROFULA. 193 

pneumonia. Catarrhal pneumonia, so frequent in early life, whether primary 
or secondary, in connection with measles, pertussis, etc., is a disease often 
involving grave consequences in those who are decidedly scrofulous, since, 
instead of resolving, the affected lung-tissue presents a strong tendency to 
caseous degeneration, ending in tuberculosis of the lungs and death. I have 
most frequently noticed cheesy pneumonia during extensive epidemics of 
measles as a complication or sequel of this disease. It may occur in those 
who are not scrofulous if the vital powers be greatly reduced, but it is so 
much more common in the scrofulous that some recent writers have desig- 
nated this form of inflammation by the term of scrofulous instead of cheesy 
pneumonia. From the fact, however, of its sometimes occurring in the non- 
scrofulous, the term cheesy or caseous — especially, too, as it expresses the 
anatomical state — seems more appropriate. 

The caseous substance which results from degeneration of the products 
of scrofulous inflammations affords a nidus in which the tubercle bacillus 
frequently obtains lodgement and conditions favorable for its propagation. 
Hence the close etiological relations of scrofula or scrofulous inflammations 
to tuberculosis. 

Prognosis. — As scrofula may be acquired through antihygienic influ- 
ences, so it may disappear or become latent through influences of an opposite 
character. Therefore the manifestations of scrofula may be limited to a brief 
period, or they may occur at intervals through the whole of childhood and 
the first years of youth. When the diathesis is inherited and fostered by 
unfavorable circumstances, the scrofulous affections appear earliest, are most 
varied and severe, and continue longest. 

In most cases, with proper treatment, the prognosis is good, but the dan- 
ger to life depends on the nature and extent of the scrofulous inflammation. 
The most common unfavorable result is the occurrence of pulmonary or gen- 
eral tuberculosis, the caseous substance, as we have said, affording a favorable 
nidus for the development and propagation of the tubercle bacillus. This is 
the usual result in cheesy pneumonia. The next most common cause of 
death, either directly or indirectly, is inflammation of the osseous system. 
Many deaths occur from inflammation of the vertebrae or of the hip or knee- 
joint when it has been allowed to continue a considerable time without proper 
treatment. Protracted suppurative inflammation of the bones is liable to 
produce amyloid degeneration of organs, which is permanent and likely to 
prove fatal, or death may occur from exhaustion, with or without tubercu- 
losis. Among the city poor meningitis is not very uncommon, consequent 
on long-continued otitis media and caries of the petrous portion of the tem- 
poral bone. Permanent impairment of sight and hearing often results from 
neglected strumous ophthalmia and otitis. 

At puberty the strumous affections gradually become less frequent, and 
they finally disappear in advancing age. Among the most robust adults are 
some who in early life presented indubitable symptoms of the strumous 
diathesis. 

Treatment. — Prophylactic. — Measures designed to prevent scrofula are 
impossible without the co-operation of willing and intelligent parents. It is 
evident that the prevention of congenital scrofula requires the treatment of 
disease or impaired health in the parent. If parents should be taught or 
should remember that good health in themselves is the necessary condition of 
the inheritance of a sound constitution in the child, and would adopt such 
therapeutic and regimenal measures as would procure this, the number of 
cases of inherited scrofula would be materially reduced. 

As the first years of life are very important, both for correcting the 
diathesis when inherited and for preventing its development in those of sound 
13 



194 CONSTITUTIONAL DISEASES. 

constitution, care should be taken that the regimen of the child be such that 
it does not cause deterioration of the general health. The nursing infant, 
if the mother be in poor health, should be provided with a healthy wet-nurse, 
for in young children the diathesis may be acquired solely by the use of food 
that is scanty or of poor quality. Those old enough to be weaned should 
have plain and nutritious diet, with a proper admixture of animal food. More 
or less outdoor exercise and residence in a salubrious locality, with sufficient 
air and sunlight, are also requisite. 

Curative. — Since scrofula originates in a state of weakness existing in the 
parent in the congenital, and in the child in the acquired, form of the disease, 
and is characterized by feeble resistance of the tissues to irritating agents, 
the inference is reasonable that all tonics have, to a certain extent, an anti- 
scrofulous effect upon the system. The ordinary vegetable tonics, and some- 
times the ferruginous, are indeed useful in the treatment of scrofula. 
Employed in connection with proper regimenal measures, they are sufficient, 
in many cases, to remove the diathesis after a time or render it latent. 
Besides the medicinal agents, which tend to correct the scrofulous diathesis 
by their general tonic effect, there are certain others which experience has 
shown to be beneficial in the treatment of scrofulous affections, and which 
are therefore largely used. One of these is cod-liver oil, which contains 
iodine among its many ingredients. 

Cod-liver oil is useless or nearly so in the torpid form of the diathesis, 
which is characterized by an increased deposit of fat in the subcutaneous 
connective tissue, slow circulation, and sluggish muscular movements. On 
the other hand, in the treatment of the erethitic form it possesses real value. 
Its protracted use in such cases does so modify the molecular condition of 
the tissues that they are less liable to inflammation, and the diathesis is there- 
fore rendered milder or removed. From one to three teaspoonfuls, according 
to the age, should be given three times daily. While we frequently expe- 
rience so much difficulty in administering it to adults affected with tubercu- 
losis, and sometimes find it necessary to discontinue its use on account of its 
nauseating effect, scrofulous children rarely refuse to take it, and it does not 
seem to diminish their appetite. 

Iodine is justly celebrated as a remedy in the treatment of scrofulous 
maladies, but it is a question whether it has not been overrated as a remedy 
for the diathesis itself. Iodine employed internally is especially serviceable 
in glandular hyperplasia and in scrofulous thickening and induration of the 
connective tissue and periosteum. In general, it should not be administered 
to children in its isolated state, on account of its irritating properties, but 
one of its compounds should be employed. The compounds which are chiefly 
prescribed in the treatment of scrofula are the iodides of starch, iron, potas- 
sium, and sodium. If, as is frequently the case, the patient be pallid and his 
appetite poor, the iodide of iron should be preferred ; if not in this cachectic 
state, the iodide of starch may be used. Pharmaceutists prepare syrups of 
both these iodides, so that the}^ can be readily administered to the youngest 
child. The iodide of starch may be administered by dropping from one to 
five drops of the officinal tincture of iodine on a little powdered starch and 
giving it in syrup. These iodides are preferable to the iodides of potassium 
and sodium for internal administration to children, since they are not irritat- 
ing to the mucous membrane and the iodine is readily set free. Prof. Dalton 
has, indeed, demonstrated that the iodide of starch is decomposed in most of 
the liquids of the body and the iodine liberated. 

In New York City a large proportion of the scrofulous children are cachec- 
tic and need iron, and the iodide of iron is more frequently employed, and 
with good results, than any other iodine compound. The syrup of the iodide 



SCROFULA. 195 

of iron, which is readily absorbed, should be given in one- to two-drop doses 
three times daily to a child of six months, and one additional drop be added 
for each additional year. Among the vaunted remedies of scrofula are phos- 
phoric acid and the phosphate of lime. I have not employed these agents 
without at the same time using other remedies, and cannot say, therefore, to 
what extent they have been curative in my practice. Probably there is no 
better combination of remedies for the strumous diathesis than the following, 
which is now used in some of the institutions of New York, and which we 
have already recommended in the treatment of rachitis : 

R. 01. morrhua?, 2 parts ; 

Syr. calcis lactophosphat. , 1 part ; 

Aquae calcis, 1 part. — Misce. 

Dose : One teaspoonful to a dessertspoonful three or four times daily. 

The syrup of the iodide of iron should be given at the same time in three 
daily doses, but not mixed with the above preparation of oil and lime, as a 
double decomposition occurs from the admixture. 

The internal use of mercury as an antidote for scrofula is now generally 
discarded. Unless, perhaps, in those cases in which the diathesis is imme- 
diately dependent on syphilis, its use for this purpase, from what we know 
of its therapeutic effects, would probably be more injurious than beneficial. 
Among the medicines which have from time to time been employed for the 
cure of scrofula, some of which have had considerable reputation, but have 
nearly fallen into disuse, are walnut-leaves, sarsaparilla, elecampane, conium, 
digitalis, horseradish, compounds of silver, gold, arsenic, baryta, and bromine. 
It is probable that none of these has any effect on scrofula or scrofulous ail- 
ments except such as improve the appetite and general health, as horseradish. 

The same hygienic measures are required in the treatment of scrofula as 
are employed in the prophylaxis of it. The nursing infant should have 
healthy breast-milk, and if its mother belong to a tubercular or scrofulous 
family or be feeble, a healthy wet-nurse should be employed, or it should be 
sent to the country, where suitable cow's milk as well as pure air can be 
obtained. The expressed juice of beef slightly boiled, the peptonized beef 
or beef tea prepared as recommended for rachitic infants, given several times 
daily in small quantity to infants, aid materially in restoring a better nutri- 
tion of the tissues. Obviously, similar care is necessary in the selection and 
preparation of the food of children who have passed beyond the period of 
infancy. While the diet should be highly nutritious, it should be plain and 
easily digested, and given at sufficient intervals, so as not to overtax diges- 
tion. The cow's milk employed should be of the best quality, and for young 
children it may be best to peptonize it. 

Fresh air, outdoor exercise, daily bathing, personal and domiciliary clean- 
liness, are very necessary for the successful treatment of the diathesis. Since 
scrofula is comparatively infrequent in farming sections, scrofulous families 
are greatly benefited by farm-life, with all the accessories to health which 
pertain to it. The use of sea-air and sea-bathing has, according to the testi- 
mony of several observers, been very efficacious. Dr. F. P. Henry states 
that no other remedial measure is so efficacious as these (Annual of Uhiver. 
Med. Sci., 1889). Dr. Valcourt, who is in charge of the Maritime Hospital 
at Cannes, where scrofulous children receive daily sea-baths during a consider- 
able part of the year, read an interesting paper in commendation of its use 
before the Pediatric Section of the Ninth International Medical Congress in 
1887. Alexander quotes the statistics prepared by Cazin. which show that 
the mortality of scrofulous children is much less in the hospital at Barek, 



196 CONSTITUTIONAL DISEASES. 

where sea-bathing is employed, than in two Parisian hospitals (I/iverp. Medico- 
Chir. Journ., 1888). 

The local scrofulous ailments require additional and special treatment. 
Those located on the cutaneous and mucous surfaces are less dangerous, as 
a rule, than the deeper-seated inflammations ; still, they should be promptly 
treated, not only for the inconvenience and annoyance which they cause, but 
because they may give rise to hyperplasia of the neighboring glands, as we 
have stated elsewhere. Thus, pharyngitis may cause a peripharyngeal ade- 
nitis and abscess, and a bronchitis may cause adenitis of the bronchial glands, 
with the probability of their cheesy degeneration. The so-called bronchial 
phthisis is believed to result, in a large proportion of cases, from a strumous 
bronchitis which has been allowed to continue uncontrolled by medicine, and 
a similar state of the mesenteric glands may result from intestinal catarrh. 
Inflammation of the skin or mucous surface occurring in the strumous requires 
the continued use of antistrumous remedies, conjoined with such treatment, 
designed to act locally, as is appropriate for the case. 

It is the common practice to treat the enlarged glands of struma by daily 
applications over them of the stronger iodine preparations. This treatment 
does not cause absorption of the redundant gland-substance. It causes pro- 
liferation of the epidermic cells, and quickens the cell-change in the adjacent 
gland and accelerates suppurative inflammation. I once produced accident- 
ally such an amount of vesication over an enlarged, hard, and apparently 
indolent gland in an infant of fourteen months that I was very anxious lest 
a sore should result which would heal with difficulty, and yet, instead of dis- 
persion of the glandular swelling, the pathological processes were so promoted 
that suppuration and discharge of pus occurred by the time that the cuticle 
had re-formed. 

When scrofulous glands have undergone degeneration they should be 
removed with the knife. It is necessary to completely extirpate the gland 
by a dissection which includes the entire gland-structure. Merely opening 
the gland, removing its contents, and curetting its cavity, as are sometimes 
practised, is not sufficient. It is well also to cut away all cicatricial tissues 
in order to secure union with as little deformity as possible. 

We know no better substance for the local treatment of strumous adenitis 
than iodine, and it should be applied, in my opinion, in such a manner that it 
is absorbed with the least possible irritation of the gland. The following will 
be found useful ointments and solutions for the treatment of these cases : 

R. Potas. iodidi, 3j ; 

Ung. stramonii, ^j. 

To be rubbed over the gland several times daily. It should not be applied 
as a plaster, since it is too irritating and will vesicate. I have known a 
glandular swelling which had continued about three months to disappear in 
three weeks under its use in connection with internal remedies. Lanolin may 
be employed in place of the stramonium ointment, inasmuch as it is believed 
to be more readily absorbed than most oleaginous substances. Another useful 
iodine mixture for these cases is the following : 

R. Liq. iodinii composita, 

Glycerini, equal parts. 

To be applied as an inunction. Glycerin renders the skin soft and in a state 
favorable for absorption. 

In The Medical Press and Circular for August 3, 1870, J. Waring Curran 
states that he has used with great success what he designates a new iodine 
paint, consisting of half an ounce of iodine, the same quantity of iodide of 
ammonium, twenty ounces of rectified spirits, and four ounces of glycerin. 



SCROFULA. 



197 



Mercurial ointments have been recommended by writers of reputation for 
the treatment of these glands. I have employed them and know them to be 
employed, but cannot say that I have ever observed any benefit whatever 
from their use. In the children's class at the Out-door Department at Belle- 
vue we have discarded them entirely for this purpose, although both the 
citrine and white precipitate ointments, diluted with an equal quantity of 
lard, have been used with apparent benefit for chronic coryza of a strumous 
nature, and also occasionally for external otitis of the same nature. 

The application of cold over an inflamed lymphatic gland and the adjacent 
inflamed connective tissue is a useful adjuvant to the treatment in many cases 
at an early stage. A small India-rubber bag containing ice, or muslin fre- 
quently wrung out of ice-water and applied over the inflamed parts, contracts 
the vessels, diminishes the activity of the morbid process going on underneath, 
and aids materially in the resolution. When the gland becomes so actively 
inflamed or the inflammation so advanced that redness of the skin occurs, 
applications of iodine are no longer proper. They increase the local disease. 
There is no longer any probability of resolution of the gland, and poultices 
should be applied. 

It is important that the diseases of the osseous system should receive early 
treatment, but, unfortunately, it is in reference to these inflammations that 
error of diagnosis is frequently made. Thus I have known periostitis, with 
the diffused redness of the skin and heat which it produces, to be mistaken 
for erysipelas, until the diagnosis was corrected from its persistence and non- 
extension. It is remarkable that strumous arthritis sometimes appears in 
two or more joints at once, as in the case related below. I have known it to 
occur nearly simultaneously in three joints, though only for a brief time in 
two of the joints, while it was chronic in the other. Hence, the fact that 
this inflammation is often mistaken for inflammatory 
rheumatism, and treated as such for some days till its 
nature becomes apparent, and in like manner the febrile 
movement, lassitude, abdominal pain, etc. of vertebral 
caries are in a large proportion of cases attributed to 
something else, and the true disease not suspected till 
irreparable damage has occurred, or much longer con- 
finement and treatment required than would have been 
necessary with an earlier diagnosis. 

The common strumous inflammations of the osseous 
system which involve the joints, as Pott's disease, hip 
disease, and white swelling, are usually quite amenable 
to treatment, early applied, which ensures complete 
rest ; but, as a rule, cases neglected or wrongly treated 
go from bad to worse. There are exceptions, for a case 
may do well or terminate with moderate deformity 
without treatment, as in the following interesting in- 
stance, which also shows the difficulty which often 
attends diagnosis : 

Anna D , aged six years, came to the children's 

class in the Out-door Department at Bellevue in February, 
1877, with the following history : Her health was good till 
two years ago, when she complained of pain of a mild form 
in both knees. Her parents attributed it to her rapid 
growth, and she was always able to walk with little suffer- 
ing. Slowly but steadily these joints began to swell. She 
has had no pain in other joints, and no member of the family has had rheumatism 
except a grandparent. She walks without complaint to the rooms ol' the Bureau. 



Fig. 37. 




198 CONSTITUTIONAL DISEASES. 

The affected joints are about equally swollen, and it is evident on examination that 
they contain some serous effusion. Direct pressure is not painful, but pressing the 
bones together with a twisting or rotating movement gives some pain. She is pale 
and has a strumous aspect. A sister of fifteen years has a similar swelling of one 
knee which began at the age of seven or eight years, but which has received no 
regular treatment, has not prevented the free use of the limb, and has given her 
little inconvenience. 

The ph}*sicians who have examined this child, one of whom is an expert in 
orthopaedic surgery, agree that the disease is strumous and not rheumatic, and that 
it did not, during two years of neglect and unrestrained motion, go on to suppura- 
tion and destruction of the joints was probably due to her good general health. 

Though the result in the above case was good, since there was little 
impairment in the use of the joints and no suffering, yet delay and neglect 
in the treatment of those strumous inflammations which involve the joints 
are exceedingly dangerous, for if left to themselves they most frequently 
end in suppurative inflammation and ulceration, with all the sad conse- 
quences which these entail. Strumous inflammations of the osseous system 
now receive more early and correct treatment than formerly, and orthopsedia, 
almost unknown till within the last twenty years, has become an important 
branch of surgery. Formerly in New York, especially in the tenement- 
houses, we often met emaciated bed-ridden children with strumous osteitis 
and arthritis, their limbs swollen and painful in motion, and offensive from 
the discharge, for the most part shunned by physicians, and with no prospect 
of relief except by amputation, Now this spectacle is comparatively infre- 
quent. The early symptoms of these diseases being better understood and 
sooner recognized, the plaster-of-Paris or starch dressing to ensure immo- 
bility, or ingeniously devised steel splints which produce extension and allow 
motion of the limb without friction of the inflamed surfaces, coming into 
general use, a large proportion of cases do not go beyond the first stage and 
are cured. 

Strumous Ophthalmia. 

[Written by Dr. O. D. Pomeroy, Surgeon to the Manhattan Eye and Ear Hospital.] 

Strumous ophthalmia in young children, as described by the older writers, 
is simply a keratitis or inflammation of the cornea, and is usually of the fol- 
lowing varieties : phlyctenular or herpetic keratitis and diffuse or paren- 
chymatous keratitis. Perhaps it is a misnomer to designate these affections 
strumous. This general principle governs most cases of these inflamma- 
tions — to wit, depressed vital energy, which is a prominent characteristic of 
the strumous diathesis. As is well known, the cornea is a tissue of low 
vitality, and any constitutional state accompanied by depression predisposes 
to an attack of keratitis. One of the commonest hospital experiences is to 
see a mild case of catarrhal conjunctivitis which should be self-limiting 
gradually extend to the cornea, causing an ulcerative keratitis. I believe all 
ophthalmic surgeons hold that the presence of corneal disease, not dependent 
on an obvious or specific cause, points to diminished vitality on the part of the 
patient. 

Herpetic or Phlyctenular Keratitis is the most frequent variety of 
corneal disease in children. It is a question whether it commences with a 
vesicle on the cornea or a papula ; but in either case it soon becomes an 
ulcer. Ciliary injection probably precedes it, although this can by no means 
be always observed. In some patients the characteristic symptom— to wit, 
photophobia — may exist for a long time without injection of the eyeball or 
any corneal changes whatever, but sooner or later it is probable that other 
characteristic signs of the disease will make their appearance. The photo- 



SCROFULA. 199 

phobia is frequently accompanied by blepharospasm, making it wellnigh 
impossible to separate the eyelids. When, however, this is accomplished, 
abundant tears gush forth, the child exhibiting signs of extreme distress. 
When the vesicle or papula is in a state of ulceration in the earlier stage, 
there may only be seen a minute loss of corneal tissue, without any opacity 
whatever. Soon, however, the ulcer becomes more or less opaque, perhaps 
seeming to be only a minute whitish spot on the cornea. This usually shows 
the commencement of reparative action. If the disease continue long, a 
general conjunctivitis sets in, more especially of the ocular conjunctiva. 
Frequently there will be only one or not more than two or three ulcers, but 
in exceptional cases the cornea may have the periphery studded with phlyc- 
tenule, which, instead of promptly healing, proliferate so as to form elevated 
nodules, the so-called " scrofulous nodular bands." If the ulcers in any case 
continue long, a number of blood-vessels shoot out from the conjunctival 
border of the cornea, quite up to the ulcer, producing what may be termed 
a vascular keratitis. The discharge from the eye is often very acrid, causing 
catarrh of the lachrymal canals, and even of the nares. Herpetic or ec- 
zematous eruptions on the cheeks or the lip near the nostrils are often seen, and 
may sometimes appear to be the cause of the disease rather than the effect. 
In this condition the upper lip may swell considerably, giving the patient a 
very " strumous " appearance. 

The duration of phlyctenular keratitis is exceedingly variable ; two or 
three weeks may bring it to a close or it may continue many months. The 
patient's general condition probably determines its duration as much as any 
other factor. If an ulcer perforate the cornea, staphyloma and anterior 
synechia may result, rendering recovery more tedious and incomplete. The 
diagnosis of this malady is not difficult. The photophobia so characteristic 
of keratitis is present in no other disease except iritis, and this disease chil- 
dren rarely have ; the little speck, spot, or abrasion on the cornea, together 
with the intolerance of light, is wellnigh diagnostic. Photophobia is present 
in most forms of corneal disease, though not in all. The causes of phlyc- 
tenular keratitis are as follows : Any condition of the system known as 
strumous, or whatever tends to lower the vital powers of the patient, affords 
a, predisposing cause. Exposure to cold or sudden change of temperature is 
the common exciting cause, leaving out of the question any cutaneous dis- 
eases. Naturally, any cause which produces a conjunctivitis may also pro- 
duce this disease secondarily. The process of dentition may have something 
to do with the eye disturbance, or any disorder of the intestinal canal ; the 
latter, however, being rather predisposing than exciting causes. This dis- 
ease also frequently occurs in patients affected with aural or nasal catarrh, 
but the condition of such children approximates closely the state designated 
" strumous." 

The prognosis in a large number of cases is very favorable. The 
opacities of the cornea left after the healing of the ulcerations are the 
principal difficulties in the way of a good recovery. If the opacities are 
in the proper substance of the cornea, we are not certain that they will dis- 
appear by absorption, though they may. Nothing is more difficult than to 
determine this point. In the epithelial and Bowman's layers, as well as the 
posterior layer, opacities readily disappear. When the ulcer perforates the 
cornea we have an anterior synechia and the appearance known as myo~ 
cephalon, which usually disfigures the eye more or less for life. 

One discouraging point about these opacities is that, although they dis- 
appear, the cornea is left with a somewhat distorted curvature, causing irreg- 
ular astigmatism, and if they chance to be near the centre oi' the cornea 
great disturbance to vision results. I have often, in fitting spectacles, 



200 CONSTITUTIONAL DISEASES. 

noticed that the patient's vision was less than normal, and on investigation 
have found a history of an infantile keratitis which had done all the mis- 
chief. In those cases described as having " scrofulous nodular bands " the 
proliferative nodules are very likely to undergo a variety of degenerations 
which do not end in a properly restored cornea. One great difficulty in mak- 
ing an exact statement here is the tendency of the keratitis to recur, and it. 
cannot be determined where the process will cease after a number of 
recurrences. 

Treatment. — As the fifth nerve presides over the ciliary vaso-motory 
system of the corneal nutritive supply, it is obvious that treatment calcu- 
lated to correct any of its morbid manifestations would be rational. Such is 
found to be the fact. Sulphate of atropia, in solution of one to two grains to 
the ounce, dropped into the eye three times daily, is probably superior to any 
other treatment. It inclines to break up the orbicular spasms, relieving the 
photophobia and ciliary neuralgia, diminishes vascularity, and contributes 
more to the relief of the patient than any other one remedy. If the pain 
be severe, the atropine may be used six or eight times daily, or it may be 
even instilled every fifteen or twenty minutes until pain is relieved. If an 
over-effect be reached, the patient complains of dryness in the throat, possi- 
bly pain in the head, or he may have other cerebral disturbances, when the 
drops may be discontinued for a time. Muriate of pilocarpine in two-grain 
solutions may be used in a similar manner and for the same purpose ; but it 
contracts the pupil and renders the accommodation tense, the very opposite 
to the atropine effect. I have not as much confidence in this remedy. A 2 
per cent, solution of cocaine, instilled, will sometimes relieve the spasm and 
pain temporarily. Powdered calomel may be dusted into the eye every 
second day. A small quantity only should be used, since it is apt to col- 
lect in masses which act as foreign bodies (we desire to produce irritation for 
a few minutes only). A drachm of table-salt to a pint of water may be used 
to bathe the eyes freely four or five times a day, used warm or cold accord- 
ing to the patient's pleasure, although warm applications are more likely to 
be well received. Red precipitate ointment (R. Vaseline, £j ; hyd. ox. rub. 
in very fine powder, gr. j to ij. — Misce.) placed under the eyelids every day 
or two, is often very beneficial ; also the yellow precipitate ointment, made in 
the same manner, has a similar effect. Occasionally the ulcers show a disin- 
clination to heal, when they may be touched with Arg. nit. gr. x to xxx ; 
aquae dest., ^j. — Misce. Wind a bit of absorbent cotton on a probe, dip this 
into the solution, and touch the ulcer, but no other point. Cupri sulph., in 
solution of the same strength, may be used for the same purpose. A platinum 
probe, heated to a red heat in a spirit lamp, is much used at present. A few 
drops of a 2 per cent, solution of cocaine, previously instilled, will prevent 
pain from these applications. A protective bandage exerting moderate pres- 
sure on the eye sometimes does good, but it should not cause discomfort. 
If there be much spasm of the orbicularis, however, it is not indicated. If 
the pain in the eye continue and the orbicularis be in a state of spasm, can- 
tholysis may be performed ; that is, divide the external canthus so as to cause 
the lid no longer to press hard upon the eyeball, and close the wound thus 
made by stitching the skin to the conjunctiva above and below the incision, 
placing one stitch in the extreme outer canthus. The result of the ope- 
ration is temporarily to break the power of the orbicularis, so as to arrest 
the spasm. This measure accomplishes in some cases what nothing else will. 

If the eye be painful, without spasm of the lid, and there be great pho- 
tophobia, whether the eyeball be too hard or not, paracentesis may be done. 
The mode of performance is described in the treatment of ophthalmia neonati 
in another place in this book. After a while the accompanying conjunctivitis 



SCROFULA. 201 

may need treatment in the ordinary way. Indeed, astringents may often be 
used quite early to obviate the irritating effects which occasionally result 
from the use of atropine. If an ulcer refuse to heal after the treatment 
already laid down, iridectomy may be performed, although this is not often 
resorted to. Occasionally an ulcer may be cut across by passing a narrow 
Graefe's knife through it, making a puncture on one side and a counter-punc- 
ture on the opposite side, and then cutting out quite through the ulcer, divid- 
ing it into two equal parts. All needful treatment for the constitutional 
condition of the patient should be attended to. So necessary are fresh air 
and sunlight that I would never shut the patient in a dark room. Blue or 
smoke-colored glasses may be worn to protect the eyes from a strong light, 
and in some cases the eyes may be protected by a bandage of some dark 
material, so that the patient may be taken for an airing without suffering. I 
would, however, advise that the eyes be accustomed to the light as much as 
is possible without causing pain. 

In Parenchymatous or Diffuse Keratitis we have quite a different array 
of symptoms. The margin of the cornea near the limbus may show a decided 
zone of injection of the conjunctival and episcleral vessels. It may be so 
excessive as to consist apparently of a rosy ring surrounding the cornea. 
These vessels after a time shoot inward, and may involve a large part or even 
the whole of the cornea. In other cases, designated non-vascular diffuse 
keratitis, the injection is very slight indeed, and sometimes apparently want- 
ing altogether. In either case, however, the same consequences result : the 
cornea becomes diffusely clouded, the process generally, but not always, com- 
mencing at the limbus. This cloudiness may be quite without lines or dots 
of opacity, like ground glass. Again it may appear composed of innumer- 
able minute opaque points or lines running in various directions. At first, 
the corneal epithelium escapes, presenting a regular and uniform polish, but 
afterward it becomes opaque. Again, if the process involve the whole of the 
cornea, minute opaque spots may be seen in Descemet's membrane, giving it 
some of the characteristics of keratitis punctata. In the earlier stages there 
may be some pain and intolerance of light, but as a rule the disease, for a 
corneal affection, is comparatively painless. The duration of this disease is 
never short ; it may continue for many months, and it shows a strong tend- 
ency to relapse. The most frequent causes are hereditary syphilis and 
struma. Mr. Hutchinson of London always examines the teeth of these 
patients to see if there be anything characteristic of hereditary syphilis. 
As similar teeth are often noticed in strongly-marked strumous subjects, it 
becomes doubly interesting to make the observation. One point is apparent 
in most of these cases : that there are in almost every patient some signs of 
badly-developed physique — that is faulty tissue-elaboration. As a rule, both 
eyes sooner or later become affected, pointing to a constitutional origin of the 
affection. 

In treatment we are often disappointed in our efforts. At the first, if 
there be pain or photophobia, atropine may be instilled and the eyes bathed 
with warm or tepid water several times a day. Tonics or alteratives are 
always indicated. One of the most useful prescriptions is the following : 

R . Hydrarg. chlor. corros., gr. j. ad jss ; 
Tine, cinchon. comp., 

Syr. aurantii, da. £iv. — Misce. 

Dose : One teaspoonful three times daily after eating. 

Iodide of potassium is frequently given, and may very properly alternate 
with the mercurial treatment ; children will bear very large doses of the iodide. 
and indeed they are often necessary in order to obtain the curative effects of 



202 CONSTITUTIONAL DISEASES. 

the drug ; I would suggest from three to twenty grains three times daily, well 
diluted with water. Both these remedies may be continued for months, but 
ptyalism should always be avoided. Cod-liver oil with extract of malt may 
be administered. Whatever tends to improve the patient's general condition 
is indicated. Exercise in the fresh air is good, but the pernicious effects of 
cold must be avoided. Paracentesis of the cornea rarely does good, but occa- 
sionally iridectomy may be of benefit. The complication of iritis or irido- 
choroiditis is not common, though it does occur. When the disease becomes 
very chronic there will be hardly vascularity enough for the purposes of 
repair. This being the case, stimulating collyria may be used, similar to 
those indicated in conjunctivitis. Olive oil and spirits of turpentine, in equal 
parts, may be applied to the eye every second day. Bathing with warm 
water sufficiently to congest the eye will sometimes be serviceable. An attack 
of acute conjunctivitis has been known to do good. But, do what we may, 
this affection sometimes runs on unchecked for a very long time. It rarely 
destroys the sight, but I recently treated a case from the beginning, and in 
spite of treatment there was only perception of light remaining. I have 
heard of only one other similar case. From some recent experiences I am 
inclined to believe that bichloride of mercury internally and atropine as a 
collyrium are of as much value as any other agents in the treatment of 
this obstinate malady. 



CHAPTEE III. 

TUBEKCULOSIS. 

The term " tuberculosis " is applied to a disease which is characterized 
by the formation of small tubercles or nodules in one or more organs. 
Though more prevalent in some countries or localities than in others, it 
occurs in all or nearly all parts of the globe from which we have exact 
information, and it has been more destructive to human life than any other 
one disease. 

Etiology. — One of the most important discoveries of recent years relat- 
ing to the etiology of diseases is that of the specific principle of tuberculosis. 
It has long been suspected by observing physicians that a specific cause did 
exist, and that this disease is to a certain extent infectious, but it is only 
recently that patient microscopic investigations have triumphed over the 
difficulties which surround this subject, and have detected the micro-organ- 
ism which has been so fatal to the human race. The honor of its discovery 
belongs mainly to Dr. Koch of Berlin. In his investigations Koch invariably 
found a certain bacillus in all recent tubercles, proving beyond a doubt that 
they always accompany the development of the tubercular nodule. By 
inoculating guinea-pigs, rabbits, and cats with tubercular material he com- 
municated tuberculosis, reproducing the tubercular nodule, in which he 
always found the same bacillus. But it still remained to determine the rela- 
tion of the bacillus to the tubercle, whether it was merely an accidental 
accompaniment, or whether it sustained a causal relation, producing the 
nodule by its irritating action on the cellular elements of the part where it 
happened to lodge. After many trials Koch succeeded in preparing a pabu- 
lum in which the bacilli grew and reproduced their kind. By adding a little 
of the first cultivation to the pabulum, he produced a second cultivation, and 



TUBERCULOSIS. 203 

after a series of cultivations he produced a bacillus which was evidently freed 
from all other substances. With the bacillus of the last cultivation he was 
able to produce the tubercular nodule, having all the characteristics which 
are observed when it is developed in the usual way in man. Different micro- 
organisms take coloration differently, and Koch was enabled to discriminate 
the tubercular bacillus under all circumstances from other microbes by the 
peculiar color imparted to it. 

The tubercle bacilli have the form of " delicate rods from a quarter to 
half the diameter of a blood-corpuscle in length." The more severe the 
tuberculosis, the greater the number of bacilli. They occur not only in the 
recent tubercle, but also in immense numbers in the periphery of the caseous 
masses of a tubercular patient. They are found not only elsewhere, but also 
in the interior of the giant-cells, as many as twenty even in some cells. They 
do not seem to have the power of movement, and oval spores are found in 
some of them. They grow in a temperature of 86° to 104° F., and not in a 
temperature outside these limits. 

As might be expected, these microscopical researches of Koch have 
attracted wide attention, and have led to a repetition of his experiments by 
many pathologists, and to new experiments relating to the etiology of tuber- 
culosis. The result has been to establish more firmly the views of Koch, and 
the doctrine that tuberculosis is a specific disease, and that the bacillus is the 
specific principle. 

Among the most thorough and convincing researches bearing on the causal 
relation of micro-organisms to tuberculosis, growing out of Koch's discovery, 
were those contained in a report to the London Association for the Advance- 
ment of Medicine by Research (Practitioner ; London Lancet, March 17, 1883). 
Experiments were made with the cultivated bacilli obtained from Koch. 
11 Twelve animals were inoculated with these organisms, chiefly into the 
anterior chamber of the eye, and all of them became tuberculous. The 
tubercles produced in these cases were infective and caused tuberculosis in 
animals. On examination of tuberculous material Koch's tubercle bacilli 

are always found, though in varying numbers About eighty organs 

of tuberculous animals and thirty-six cases of human tuberculosis were 
examined, and in all of these, without exception, tubercle bacilli were 
found." 

The discovery of Koch has already proved of great importance as an aid 
in diagnosis, for the sputum of tubercular patients contains the bacillus. 
Tubercular sputum affords a soil in which the bacillus thrives and multiplies, 
as it does in the tissues of a tubercular patient, and by careful microscopic 
examination we are able to discover it in this sputum, while it is absent from 
non-tubercular sputum. According to Frisch ( Wiener med. Woch., No. 46, 
1883), the bacilli were found without an exception in the sputum of 140 
patients with confirmed tuberculosis, while the sputum of 150 non-tubercular 
patients was in every instance free from them. Heitler ( Wiener med. Woch., 
No. 43, 1883) examined the sputum of 140 tubercular patients, 1 of whom 
had miliary tubercles, and 1 other caseous pneumonia. All the other cases 
were chronic and were grouped by the author as follows: 1st, 6 cases of old 
infiltration of the apices of the lungs, cured, with the persistence of dulnesa 
on percussion, without rales; no bacilli observed. 2d, 12 cases of tuberculo- 
sis with slight dulness and dry rales. In 2 of these, notwithstanding marked 
physical signs, fever was absent and the tubercular process was arrested 
apparently ; no bacilli. In the sputum of the remaining 10 cases bacilli were 
present in all the examinations except 2. The third group contained eases 
of advanced and progressive tuberculosis, and the fourth group eases oi' 
advanced chronic phthisis, but with remissions. In the sputum of these two 



204 CONSTITUTIONAL DISEASES. 

groups bacilli were always observed. That Heitler in 6 instances witnessed 
the disappearance of bacilli when the tubercular process was arrested is an 
interesting fact, as showing the relation of the bacilli to tuberculosis. He 
examined the sputum of 29 non-tubercular patients, patients with pneumonia, 
bronchitis, bronchial dilatation, and putrid bronchitis with gangrene, and in 
no instance found the bacilli of tuberculosis. 

As usually happens when a great discovery is announced, there are dis- 
sentients ; there are those apparently competent to express an opinion, as 
Spina and Formad, who do not accept or only partly accept the views of 
Koch. But the testimony of many observers, constantly accumulating, tends 
to establish more securely the doctrine of the microbic origin of tuberculosis, 
and it is now apparently as securely established as any doctrine in pathology. 

Koch's discovery necessitated revision of the teachings long accepted 
relating to tuberculosis. The tubercle nodule is, as we will see, an aggre- 
gation of cells produced from the cellular elements of the part where the 
nodule appears through a proliferating process caused by an irritant, and in 
the light of our present knowledge we consider the bacillus to be the irritant. 
A local corpusculation and a cellular nodule may be produced in the lungs or 
elsewhere by the lodgement of a non-specific irritant, whether organic or inor- 
ganic, as putrid cheese, particles of dust, or metallic particles, and thus far no 
cells have been discovered in nodules thus produced which are characteristic 
of tuberculosis. The giant-cells which at one time were thought to be pecu- 
liar to the tubercular nodule have been found in growths of another nature, 
as in gummata. The characteristic and peculiar element in the tubercular 
nodule is the bacillus. 

It has long been the belief from clinical observations in Southern Europe, 
and of certain observing physicians in the temperate regions of Europe and 
America, that phthisis is contagious, and the acceptance of the parasitic 
theory will probably soon render this belief an established principle in pathol- 
ogy. Already many instances have been published in the journals which 
show the infectiousness of tuberculosis, as the following : In an inland town 
in Europe a midwife with advanced phthisis had been in the habit of blowing 
into the mouths of new-born infants, and so many of them perished of tuber- 
cular disease as to excite attention and cause alarm, while those attended by 
a healthy midwife remained well. Dr. E. I. Kempf relates the following 
striking example in the Louisville Medical News for March 22, 1884 : In the 
fall of 1880 a girl of eighteen years, whose brother had died of consumption, 
was found to have tubercles at the apices of both lungs. She belonged to a 
sisterhood, and slept in the general dormitory with the other sisters. In four 
months nine of her companions began to cough and were found to have 
tubercles. No one of the sisterhood had previously had disease of this kind. 
Dr. A. Ollivier, physician to l'Hopital des Enfants-malades, Paris, states that 
a family having uniform robust health occupied two small rooms opening into 
a narrow court. The parents, a young son, and the baby slept in one of the 
rooms. An older son, who had been living elsewhere, contracted phthisis, 
returned home, and slept in the same apartment. He died January 16, 1883. 
His mother, who was constantly at his bedside, began to cough, emaciated, 
and died of the same disease in the following May. Seven days after the 
death of the mother the infant had tubercular meningitis, of which it per- 
ished ; and the older child, who occupied the same apartment, sickened and 
died like the ^mother. The father only survived of those who occupied the 
small room {Etudes d' Hygiene publique, 1886). The fact that wives devoted 
in their attendance on consumptive husbands frequently perish of the same 
disease has been long known to physicians, but it has usually been attributed 
to the depressed state of system incident to long watching and grief, and not 



TUBERCULOSIS. 205 

to any contagious property. But now that a clearer insight has been obtained 
into the nature of tuberculosis, and both microscopical researches and clinical 
facts show its communicability, more caution will be exercised in the inter- 
course with patients. 

The recent experiments of Cornet ( Wiener med. Wochen., June 2, 1888) 
have shown that the walls and furniture of a room occupied by a phthisical 
patient may be infected by the lodgement of the tubercle bacillus upon them, 
so that any one occupying this apartment subsequently is in danger of con- 
tracting the disease. He rubbed the walls and bedsteads in the ward occu- 
pied by phthisical patients with disinfected sponges, avoiding such surfaces as 
might be infected by the hands and sputum of patients ; 9-1 animals were 
inoculated with these sponges, and 52 of them died, apparently of causes 
different from tuberculosis ; the remaining 44 were killed after forty days, and 
20 of them had tubercles. 168 animals were inoculated with the dust from 
the walls of rooms occupied by phthisical patients in family practice. Of 
these animals 90 died soon afterward. Of the remaining 78, 34 contracted 
tuberculosis. In control-experiments, the dust being used from surgical 
wards, operating-rooms, and from crowded thoroughfares, the result was neg- 
ative as regards the production of tuberculosis. " It has been abundantly 
demonstrated by numerous experiments that the milk from tuberculous cows 
is capable, when ingested, of causing tuberculosis. How serious is this dan- 
ger may be seen from the statistics of Bollinger, who found the milk from 
cows affected with extensive tuberculosis infectious in 80 per cent, of the 
cases, and that from cows with moderate tuberculosis infectious in 33 per 

cent, of the cases Bollinger estimates that at least 5 per cent, of the 

cows in dairies are tuberculous. From statistics furnished me by Mr. A. W. 
Clement, V. 8., the number of tuberculous cows in Baltimore which are 
slaughtered is not less than 3 to 4 per cent." 1 

It has been shown by tests with tuberculin that the proportion of milch 
cows having tuberculosis in dairies supplying New York City is large, and 
physicians aware of this fact advise their families to Pasteurize milk designed 
for the nursery : that is, subject it to a heat of 167° for twenty minutes. The 
sterilization of milk we have treated of elsewhere. I may repeat that tuber- 
cles are found in the milk of tuberculous cows even when the udders and 
teats or lacteal tract is healthy. The frequency of tubercular milch cows in 
America is apparent when I state that more than fifty cows have been con- 
demned and slaughtered in a single dairy supplying New York City. 

The causal relation of scrofula to tuberculosis we have considered elsewhere, 
but we may here repeat that scrofulous ailments, especially the caseous prod- 
ucts, afford the soil which is favorable to the growth and multiplication of 
the bacilli. Hence these microbes are not infrequently found in scrofulous 
products, showing that the tubercular has supervened on the scrofulous dis- 
ease. Kanzler treats of the relation of scrofula to tuberculosis in the Berlin 
klin. Woch., January 14, 1884. He believes that the two diseases are distinct, 
but that, as expressed by the French reviewer, la scrofule of re un terrain de 
predilection pour le developpement de la tuberculosa He has discovered bacilli 
only in a minority of the local manifestations of scrofula, never in glands 
which had not undergone suppuration or caseation, never in eczema, impetigo. 
suppurative otitis media, and never in the nasal, conjunctival, pharyngeal, 
and vaginal catarrhs of the scrofulous. It is not till degenerative changes 
have occurred in the inflammatory products of scrofula that the bacilli oi' 
tuberculosis appear, indicating the supervention of the latter disease. 

Anatomical Characters of the Tubercle. — As Virchow pointed out, the 
tubercular nodule when recent is semi-translucent and small, attaining about 

1 Prof. W. H. Welch's Address be/ore the Amer. Med. Asso. } 1889. 



206 CONSTITUTIONAL DISEASES. 

the size of a millet-seed and consisting mainly of cells. The cells of which 
it is chiefly composed resemble the white corpuscles of the blood in appear- 
ance and size, but some are smaller and others larger than those corpuscles. 
They have been designated the lymphoid cells. Each cell when fully 
developed has a bright homogeneous nucleus, small and spherical or large and 
oval, and nucleoli. A large cell sometimes contains two or more nuclei. 
The lymphoid cells appear to be developed from the cellular element of the 
connective tissue. This is Virchow's belief. In addition to these cells, which 
constitute the greater part of the tubercle, large uninuclear cells are also 
observed, designated epithelioid cells. They resemble large and swollen 
endothelial or epithelial cells, and they are believed by pathologists to be pro- 
duced from these cells, which lie within the area of the nodule. A third cell 
also occurs, known as the giant-cell from its size. It has many nuclei, and 
occupies chiefly the central part of the nodule. All these cells, as has been 
recently shown, occur in other pathological products besides the tubercular 
nodule, and no one of them is therefore characteristic of it. But the element 
which is of greatest importance, since it sustains a causal relation to the 
disease, was, as we have seen, the last discovered. The bacillus is always 
found in the recent tubercle lying without the cells, as we have stated, but 
also in the interior of the giant-cells, for which it appears to have an affinity. 
A fibrous network with more or fewer blood-vessels surrounds the cells and 
holds them together. The blood-vessels belong to the normal tissues, and are 
not a new growth, the tubercle having developed around them. The nodules 
are single or in clusters, forming masses of considerable size. 

When the nodule has attained a certain age, caseation always occurs in 
its centre and extends outward, causing an opaque and yellowish-white dead 
mass, in which fragmentary cells can be observed under the microscope. 
Caseation is now known to be a form of decay which is common to path- 
ological products of different kinds, and is not peculiar to tuberculosis, as 
was supposed before the time of Virchow. It occurs in consequence of 
abundant exudation or cell-formation and the compression and obliteration 
of vessels. It is therefore more common in scrofula than in any other disease, 
since scrofulous inflammations afford the conditions in which it is especially 
liable to occur. The yellow tubercle is only an advanced stage of the 
semi-transparent miliary tubercle. In the cheesy metamorphosis granules 
of fat are deposited within and around the cells, and the cells shrivel and 
disintegrate. The shrunken granular and fragmentary cells were believed to 
be the true tubercular cells until Virchow pointed out their character. When 
the nodule or nodular mass becomes yellow or caseous, and circulation ceases 
in it, it is surrounded by a vascular zone in which circulation still continues. 
It is very seldom, perhaps never, absorbed, although particles of it may enter 
the lymphatics or blood-vessels and be carried elsewhere with the bacilli. It 
is an irritant, producing inflammation in the surrounding tissues, with thick- 
ening, induration, and abundant production of pus-cells, which mingle with 
the elements of the nodule. Its history henceforth is that of an abscess, and 
ulceration and discharge of the liquefied substance upon one of the free sur- 
faces is the common result. In rare instances the tubercular nodule, instead 
of cheesy degeneration, undergoes fibroid degeneration or cretefaction. 

Various pathological conditions furnish the soil in which the bacillus 
obtains lodgement and grows, and in this way becomes a cause of tubercu- 
losis. Cheesy pneumonia and exhausting suppurating surfaces often afford 
a nidus favorable for the development of the tubercle bacillus. During 
epidemics of measles many cases occur of cheesy pneumonia ending in 
tuberculosis. Cheesy and disintegrating lymphatic glands, as the bronchial, 



TUBERCULOSIS. 207 

often become tubercular, as do the inflammatory products of the grippe or 
influenza. 

Inheritance. — Csoker states that a cow advanced in pregnancy died of 
tuberculosis. In the hepato-duodenal ligament of the foetus were six enlarged 
lymphatic glands partly caseous and partly cretefied, but containing numerous 
bacilli and tubercles (Deutsche med. Zeitg., Jan. 29, 1891). Birch-Hirschfeld 
states that a woman seven months pregnant died of general tuberculosis. 
Twenty months before her death the foetus which she carried was alive. A 
Cesarean section was performed, but both mother and child died soon after. 
The mother had acute general tuberculosis ; the placenta contained numerous 
tubercles, and portions of the liver, spleen and kidneys, inoculated in the 
guinea-pig and rabbit, communicated phthisis. Baumgarten from his obser- 
vation expresses the opinion that infection of the foetus occurs in three ways — 
by a diseased ovum or fructifying sperm and by a diseased placenta. 

Prausnitz inoculated guinea-pigs with scrapings obtained from railway- 
coaches running from Berlin to Meran, in which consumptives are accustomed 
to travel. The scrapings of five coaches contained virulent tubercle bacilli, 
and Prausnitz urges the disinfection of railway-carriages. Schnirer found 
similarly infected dust, which communicated tuberculosis, lodged upon grapes. 

Inhalation. — The observations of Cornet have disclosed the fact that 
the inhalation of the dried sputum of phthisical patients is probably the most 
frequent mode in which this disease is contracted through the respiratory 
organs ; but the inhalation of the moist breath of the consumptive has in 
numberless instances conveyed the disease. 

Anatomical Characters in Infancy and Childhood. — The anatomical cha- 
racters of tuberculosis in the first years of life vary in certain particulars from 
the form which they present in the adult, but after the age of three years the 
differences are fewer and less pronounced than previously. 

Tubercular laryngitis, so common in the adult, is absent in a large pro- 
portion of cases under the age of three years, and when present it has little 
intensity. Ulceration of the larynx very seldom occurs. This has been 
attributed to the fact that there is so little expectoration in young children, 
the sputum being an irritant. Niemeyer, however, does not consider the 
sputum of tuberculosis sufficiently irritating to cause laryngitis and laryn- 
geal ulceration ; but the arguments in favor of this mode of causation, in 
my opinion, more than counterbalance those which have been presented 
against it. 

I have never met a case of tubercular ulceration of the larynx or trachea 
in the post-mortem examination of young children, nor do I recollect ever 
treating a case in which there was that degree of dysphonia which indicated 
ulceration. Rilliet and Barthez, in more than 300 necropsies of tubercular 
cases, found no ulcers in the larynx or trachea under the age of three years, 
but met 8 cases between the ages of three and ten years, and 8 between ten 
and fourteen years. The ulcers, whether seated in the larynx or in the 
trachea — and they are in most cases in the former, since the inequalities 
upon the surface of the larynx favor the retention of the sputum — are com- 
monly small, superficial, round or elongated, and with little thickening or 
infiltration of their borders. Occurring in the folds of the mucous mem- 
brane — as, for example, around the vocal cords — their form is usually 
elongated. 

Bronchitis is not infrequent. This inflammation is due to. and dependent 
on, the pulmonary tubercles, and is therefore most intense in the part o\ % the 
lung where the tubercles are most abundant and farthest advanced. Conse- 
quently, it is more intense on one side than on the other, and it may be 
unilateral. It differs in this respect from idiopathic bronchitis, which is 



208 CONSTITUTIONAL DISEASES. 

commonly nearly uniform on the two sides. It differs also in the fact that 
it is sometimes accompanied by ulcerations. The ulcers are round or elon- 
gated in the direction of the axes of the tubes, and, like those of the larynx 
or trachea, are superficial. Circumscribed inflammation may attack a bron- 
chial tube, as, indeed, the trachea, and give rise to ulceration and perforation 
from the pressure of a diseased lymphatic gland external to the tube. This 
subject will be treated of hereafter. 

Lungs. — It is well known that in the adult tubercles are always present 
in the lungs if they occur in any part of the system. I have met 2 cases in 
which the lungs were free from tubercles in 36 post-mortem examinations of 
children who died of tuberculosis. One of the two was an infant, but its exact 
age is not stated in the records. It had cheesy degeneration of the thymus 
and bronchial glands, enlargement of the mesenteric glands, but without 
cheesy degeneration, and disseminated tubercles in liver and spleen. The 
other, fifteen months old at death, had tubercular meningitis, with numerous 
granulations upon the convexity of the brain, and the other usual lesions of 
meningeal inflammation, with bronchial and mesenteric glands slightly enlarged 
and cheesy, and one of the former softened. In 1 case, then, in 18, the lungs 
had escaped the disease. Rilliet and Barthez in their statistics of the state 
of the lungs in infancy and childhood found these organs non-tubercular in 
47 cases in 312. and Hillier in 25 cases in 160. Therefore, the lungs were 
exempt from tubercles in about 1 case in 7. But it is to be recollected that 
the observations of these physicians were made at a time when all cheesy 
degenerations were thought to be tubercular, so that their published statistics 
may not have been strictly accurate. 

Pulmonary tubercles in children under the age of three years are, as a 
rule, discrete and disseminated through the lungs. In cases at this age which 
have advanced to a fatal termination we find yellow tubercles from the size 
of a pin's head to that of a shot in the different lobes ; many still semi-trans- 
parent if the disease have been of short duration, but if protracted most of 
them yellow, and here and there one softened and surrounded by condensed 
fibrous tissue. Around the semi-transparent or gray tubercles, many of which 
were growing, and therefore were in a state of active cell-proliferation at the 
time of death, vascular zones can often be detected by the naked eye. 

Under the age of three years tuberculosis exhibits but little tendency, 
perhaps none, to affect the upper lobes sooner or in greater degree than 
the lower. 

The following are the statistics relating to the site of the tubercles in the 
lungs in the cases which I have examined ; all, it is to be remembered, were 
under the age of three years : 



Tubercles disseminated throughout the lungs 26 

Tubercles disseminated throughout the two upper lobes 3 

Tubercles disseminated through right middle lobe and left lower lobe 

only 1 

Tubercles disseminated through left upper lobe only 2 

Tubercles disseminated (few and semi-transparent) in left lung only . 1 

Tubercles disseminated in three points in right and two in left lung . 1 

No tubercles in lungs 2 

~36 

Between the ages of three and fifteen years statistics show that the upper 
lobes are more liable to tubercles than the lower ; but the difference in liabil- 
ity is not great. In many cases occurring in this period the different lobes 
are affected nearly simultaneously, and not very infrequently the upper lobe 
is the last which is involved. In October, 1866, I made the post-mortem 



TUBERCULOSIS. 209 

examination of a boy who died in the Children's Service of Charity Hospital 
at the age of fifteen years, and small scattered tubercles were found in the 
lower lobe of the left lung, while all other portions of these organs were 
healthy. Rilliet and Barthez, who include in the same statistics all cases 
from birth to the age of fifteen years, found gray semi-transparent tubercles — • 

Cases. 

In the right superior lobe in 63 

In the right middle lobe in 43 

In the right lower lobe in 55 

In the left superior lobe in 65 

In the left inferior lobe in 54 

The same observers found yellow tubercles in the 

Eight superior lobe in 40 

Eight middle lobe in 28 

Eight inferior lobe in 39 

Left superior lobe in 35 

Left inferior lobe in 31 

Tubercular nodules, especially when softening commences, act as an irri- 
tant, exciting inflammation around themselves. Inflammation occurring from 
this cause is obviously likely to be protracted, continuing for weeks or months 
unless the tubercular matter be eliminated by ulceration. The highly vas- 
cular and delicate lungs of the young child are very liable to inflammation 
when they are the seat of tubercles, and as the tubercles are disseminated, 
the pneumonia is commonly more extensive than when it occurs from ordi- 
nary cases. In fifteen, or nearly one-half, of my cases there was pneumonia 
affecting portions of one or more lobes or an entire lobe. From the extent 
and position of the solidified portions it was obvious that in most instances 
the inflammation originated from the irritating effect of the tubercular matter, 
while in others it was due to hypostatic congestion, occurring in consequence 
of the long-continued recumbent position and feebleness of circulation. In 
these 15 cases the seat and extent of the pneumonia were as follows: 

Cases. 

Nearly entire right lung 2 

Nearly entire middle and lower lobe of right lung 1 

Entire left upper lobe 2 

A considerable part of both lungs • • • • 1 

Posterior parts of both lower lobes 4 

Posterior part of left lung 1 

Left lower lobe, and right middle and lower lobes ........ 1 

Left upper lobe (contained a large cavity) and posterior part of left 

lower lobe 1 

Nodules of inflamed lung around tubercles 2 

The inflammation in about one-third of the cases was due to hypostasis, since 
it occurred in depending portions, extended but little into the lungs, and sus- 
tained no relation to the amount of tubercle. It was in the stage of red — or, 
more rarely, of gray — hepatization. 

In 7 of the cases there were pulmonary cavities as large in proportion as 
we ordinarily find in tuberculosis of the adult. The seat oi' 1 was in the 
right lower lobe ; of 2, the left upper lobe ; of 1, the right upper lobe; oi' 
another, the right lung, its exact seat not stated ; and in the remaining ease 
the cavity, which was the largest of all, occupied the interior of all three 
lobes on the right side. Some idea of the size of these cavities may be 
•learned by the following extracts from the records: 1st Case. "A small 
14 



210 CONSTITUTIONAL DISEASES. 

superficial cavity communicating on one side with a bronchial tube, and on 
the other side with a small circumscribed collection of pus in the pleural 
cavity." 2d Case. " Cavity of the size of a hickory-nut." 3d Case. " Cavity 
of the size of a large hickory-nut." 4th Case. " Cavity three-fourths of an 
inch in diameter." 5th Case. " A large abscess." 6th Case. " The cavity 
occupied nearly the whole of the interior of the left upper lobe." 7th Case. 
" About half the right lung excavated into a cavity which extended through 
the three lobes." 

Circumscribed pleuritis, produced by tubercles underneath the pleura, was 
observed in 7 cases. It was ordinarily attended by little exudation except 
the fibrin, but in one case a sufficient amount of serum had been exuded to 
compress considerably the lung. Pus was not observed in any notable 
quantity. 

Emphysema was present in several cases, chiefly in the upper lobes, some- 
times vesicular, with fulness or bulging of the lung, an anaemic appearance 
of it, and doughy, inelastic feel. In other cases emphysema was interstitial, 
producing little bladders of air under the pleura, especially toward the root 
of the lung, or separating the lobules by wedge-shaped or irregular inter- 
spaces filled with air. In one case air had escaped from an emphysematous 
bladder into the right pleural cavity, causing pneumothorax and collapse of 
the lung. 

Next to the lungs, the bronchial glands are more frequently diseased than 
any other organs in the tuberculosis of infancy and childhood. They undergo 
the successive structural changes which characterize glandular inflammations 
— to wit, hyperplasia — and more or fewer of them cheesy degeneration and 
softening. In the state of hyperplasia their firmness is diminished and they 
have a pale flesh-color. Cheesy degeneration commences in one or more 
points in the gland, sometimes in the peripheral, sometimes in the central 
portion, and it extends till the whole gland presents the well-known cheesy 
appearance. When the gland softens the thick liquid has a puriform appear- 
ance, consisting of amorphous matter, fatty particles, and the shrivelled and 
disintegrated cells of the gland. Soon pus-cells occur, and their number 
increases. The cheesy gland may or may not be tubercular. If it be tuber- 
cular, the tubercle bacillus will be found in it. 

Rilliet and Barthez state that the bronchial glands were tubercular 
(caseous) in 249 cases in children, while the lungs were tubercular in 265. 
All cheesy glands, it is to be recollected, are considered tubercular. In 4 
of the 36 cases which I have examined no record was preserved of the state 
of the bronchial glands ; in 1 case there was no perceptible hyperplasia and 
no cheesy degeneration ; in 2 there was hyperplasia, but no cheesy degenera- 
tion, while in the remaining 29 cases cheesy degeneration had occurred in 
some of the glands or in parts of them, with occasional softening. The 
enlarged and caseous bronchial glands afford an explanation in part of the 
fact that the symptoms in the tuberculosis of young children differ from those 
in the adult, since Louis found the bronchial glands involved in only 28 per 
cent, of the adult cases of tuberculosis which he examined, and Lombard 
in only 9 per cent. A gland pressing upon the recurrent laryngeal or pneu- 
mogastric nerve or the trachea may give rise to dyspnoea and a cough ; or 
on the descending vena cava or one of the venae innominatae to congestion of 
the brain and meninges, intracranial serous effusion, and even thrombosis in 
the cranial sinuses. That a softened bronchial gland is not infrequently 
eliminated from the system by ulceration into a bronchial tube or into the 
trachea is well known. In one case which I observed the ulceration had 
destroyed portions of three of the cartilaginous rings of a bronchus, and the 
aperture was plugged by a cheesy fragment of a softened gland which pro- 



TUBERCULOSIS. 



211 



Fig. 38. 



truded. Occasionally, it is stated by authors, the ulceration is into one of the 
large vessels of the mediastinum, or even into the oesophagus. 

The following is an example of bronchial phthisis as it commonly occurs : 

This case, -which is not included in the foregoing statistics, was seen almost daily 
by me during its entire progress : On September 3, 1874, 1 examined an infant in the 
New York Infant Asylum who had wheezing respiration during the last eight days. 
The wheezing occurred both in inspiration and expiration, and also, though less pro- 
nounced, during sleep ; pulse 96, respiration 40, temperature normal. Its mother, 
who had charge of it, and had till recently wet-nursed it, had unequivocal symp- 
toms of tuberculosis for several months. The child was pallid and its flesh was 
soft and flabby. The fauces were perhaps a little redder than usual, but were other- 
wise normal, and a careful exploration of the chest revealed no cause of the embar- 
rassed respiration. Auscultation and percussion gave a negative result. In the 
latter part of September a troublesome diarrhoea occurred, which continued more 
or less till near death. The temperature on September 28th, October 8th, 10th, and 
11th, was 100J°, 100°, 99|°, and 100°. The pulse on October 10th and 11th was 
120 and 126. On October 8th the percussion-sound over the upper part of the right 
lung seemed somewhat duller than onj the other side, though the respiration was 
not observed to be notably changed in the area of the dulness. There was but 
little cough during the entire sickness. Death occurred on October 20th. At the 
autopsy the bronchial glands were found enlarged and cheesy, and underneath the 
right bronchus, near the bifurcation, was a softened, almost diffluent gland, as 
large as a small hickory nut and compress- 
ing the bronchus. This, no doubt, had pro- 
duced the wheezing respiration, which had 
been the chief local symptom. The lungs, 
spleen, and in less degree the liver, con- 
tained numerous small miliary tubercles. 
Certain of the mesenteric glands were also 
cheesy, but to a less extent than the bron- 
chial. The disease of the bronchial glands 
was evidently primary, the tubercles of the 
lungs and abdominal organs being appar- 
ently quite recent. The accompanying wood- 
cut, from a photograph by Mr. Mason, the 
photographer at Bellevue Hospital, repre- 
sents a posterior view of the lungs and 
air-passages. 

In no case have I found tubercles in 
the heart or pericardium, though they 
have been observed in rare instances in 

the latter. The mesenteric glands were enlarged by hyperplasia and more 
or less cheesy in 30 cases, were apparently normal in 2 cases, while in the 
remaining 4 cases their condition was not stated. In most of the patients 
the mesenteric glands were smaller and less cheesy than the bronchial, but 
in a few instances they were larger than the bronchial and more cheesy. 

It is a noteworthy fact, as bearing on the causal relation of these glands 
to tubercles, that not infrequently the amount of hyperplasia and cheesy 
degeneration occurring in the former was very considerable, while the tuber- 
cles in the lungs or elsewhere were small, even minute, semi-transparent, and 
apparently of recent formation. It was evident in such cases that the gland- 
ular hyperplasia and degeneration, bronchial or mesenteric, or both, preceded 
the tubercular disease, and furnished the conditions favorable for the lodge- 
ment and propagation of the tubercle bacillus. Since the cases which fur- 
nished the above statistics occurred my clinical experience with tubercu- 
losis has greatly increased, but nothing new or different has been observed 
at autopsies. 

Abdominal Viscera — Bollinger says : " The upper half of the alimentary 




212 CONSTITUTIONAL DISEASES. 

tract (mouth, throat, oesophagus, stomach, duodenum, and jejunum) offers an 
unfavorable site for tuberculosis. The lymph-follicles of the ileum and large 
intestine are the organs usually infected when the disease has its origin in 
the alimentary tract. However, primary tuberculosis of the cervical lymph- 
atics in children occurs through infection of the throat. Primary tubercu- 
losis of the intestine, combined with tuberculosis of the peritoneal lymphatic 
glands, occurs oftener in children than in adults, the cause of which is prob- 
ably to be sought for in the feeding of young children with the milk from 
tubercular cows." In children tubercles in the solid organs of the abdomen 
rarely give rise to appreciable symptoms, since they are small and dissemi- 
nated, not impairing materially the function of the part in which they are 
located. On the other hand, peritoneal and intestinal tubercles and the 
enlarged and cheesy mesenteric glands give rise to symptoms which require 
description. The most frequent seat of peritoneal tubercles is upon the 
attached surface of the peritoneum, where they are formed in the connective 
tissue. They are distinctly seen through the peritoneum, and cause some 
prominence of it. Exceptionally their seat is upon its free surface. Every 
portion of the peritoneum, whether visceral, parietal, or omental, is liable to 
tubercles, but general tuberculization of so extensive a surface seldom occurs 
in any one case. The tubercles are spherical or lenticular, and most of them 
small. Sometimes they are very numerous, but so minute as to be scarcely 
visible. They are gray or yellow according to their age. Peritoneal tuber- 
cles often produce circumscribed peritonitis, causing adhesion of opposite sur- 
faces. The tubercles in themselves cannot be detected by external palpation ; 
but masses composed of tubercles and inflammatory products are sometimes 
so large that they can be felt through the abdominal walls. 

The symptoms of peritoneal tuberculosis are attributable, for the most 
part, to the peritonitis. Among them may be enumerated abdominal tender- 
ness or pain, meteorism, ascites — usually slight — and derangement of the 
bowels, commonly diarrhoea. Since tubercles in this situation occur, in most 
cases, subsequently to tubercles elsewhere, the symptoms which have been 
described are associated with and are subordinate to others. 

Stomach and Intestines. — The most common seat of gastro-intestinal tuber- 
cles is the small intestine, and more frequently its lower portion, near the 
ileo-caecal valve, than its upper or central. They are rare in the duodenum 
or contiguous part of the jejunum. They are developed ordinarily in the 
connective tissue, either that lying under the mucous or the serous surface. 

Gastro-intestinal tubercles are often accompanied by ulceration of the 
adjacent mucous membrane. But in a certain proportion of cases, probably, 
the tubercles do not cause the ulcers, for ulceration of this membrane is not 
infrequent in the tuberculosis of children, when there are no tubercles in the 
walls of the stomach or intestines. The following statistics of Rilliet and 
Barthez relating to this point will aid to an understanding of the symptoms : 

rr.ii- 11 ^x x. n f with ulcers, 6 cases. 

Tubercles m walls of stomach, 7 cases, ^ j ^^ ^^ ± cage 

Ulcers of gastric mucous membrane, without gastric tubercles, 14 cases, 
rp i t • n • , ,• 00 f with ulcers, 70 cases. 

Tubercles m small intestine, 82 cases, { without ulc ' ers> 12 cases . 

Ulcers without tubercles in small intestine, 51 cases. 

m -, , . , .... n ^ f with ulcers, 10 cases. 

Tubercles in large intestine, lo cases, { without ulc ' ers> 5 cases . 

Ulcers in large intestine, without tubercles, 47 cases. 

The ulcers have vascular, thickened, and infiltrated borders. Their diam- 
eters vary from a line to half an inch or more, and their general form is 



TUBERCULOSIS. 213 

circular, or. if two or more unite, irregular. Tubercular ulcers of the 
stomach are mostly in the great curvature, those in the small intestines in 
the ileum and lower part of the jejunum, and those of the large intestine in 
the caecum. 

The following table exhibits the state of the principal abdominal viscera 
in the 36 cases embraced in my statistics : 

Liver. Spleen. Kidneys. 

Tubercular 12 22 1 

Non-tubercular 16 6 21 

Not stated 8 8 14 

Fatty 5 

In no instance did I observe tubercular softening in the abdominal organs, 
and a large proportion of the tubercles in the liver, spleen, and kidneys were 
still in the first stage. In the 5 cases in which the liver was recorded fatty, 
this state of the organ was obvious to the sight, as it is in tuberculosis of 
the adult. A moderate excess of fat in the hepatic cells may have been 
present in some of the other cases, but it was not sufficient to be appreciable 
without the microscope. It is to be remarked that in the 5 cases in which 
the liver was recorded fatty this organ contained no tubercles. The spleen 
is seen to have been the most frequent seat of tubercles of all the viscera, 
except the lungs. In 14 cases the intestines were examined ; and in 5 
tubercles discovered, developed in their connective tissue. The intestinal 
tubercles were small, and ulceration had occurred of the mucous membrane 
which covered them. 

The brain was examined in 15 cases. In 12 the amount of cerebro-spinal 
fluid varied from ^ss to gv by estimation. In 2 others the records state that 
there was a considerable amount of this fluid, the exact quantity not being 
given, while in the remaining case congestion of the brain and meninges was 
noticed, but nothing was recorded in regard to the amount of cerebro-spinal 
fluid. The increase of the cerebro-spinal fluid in tuberculosis is attributable 
to wasting of the brain, a hydrocephalus ex vacuo, and in some cases to passive 
congestion and serous transudation, due to feeble circulation, or obstructed 
flow from the pressure of bronchial glands on the vessels within the thorax, 
as already stated. 

Tubercles were present in the pia mater in 3 cases : in 2 with fibrinous 
exudation ; in the other without fibrin or other evidence of inflammation. 
Tubercular meningitis is described in another part of this book. 

Symptoms. — The symptoms in tuberculosis of children arise in part from 
the diathesis and in part from the tubercles. Before the period of tubercles 
there are signs of failing health, such as loss of appetite, flabbiness of the 
soft parts, or emaciation, lassitude, and loss of strength. These symptoms 
continue after the formation of tubercles, and increase. 

The features are ordinarily pallid, but during the paroxysms of fever, to 
which tubercular patients are subject, they may be flushed. Lividity of the 
features, due to imperfect decarbonization of the blood, occurs if there be 
enlarged bronchial glands which compress the vessels within the thorax, or 
if there be extensive pulmonary tuberculization or pulmonary tuberculiza- 
tion, whether extensive or not, which is complicated by capillary bronchitis 
or pneumonia. 

The skin is nearly natural, or it loses its flexibility and softness and 
becomes dry and rough. In some patients there is, at times, general or par- 
tial furfuraceous desquamation of the skin, due to- exaggerated development 
of the epidermis. Children, like adults, notwithstanding the general dryness 
of the surface, are liable to perspirations at night and in sleep. This symp- 



214 CONSTITUTIONAL DISEASES. 

torn is less frequent at the commencement than at an advanced period, in 
acute than in chronic cases, and in those under three or four months than in 
older children. It is more abundant about the head and limbs than else- 
where, and is sometimes confined to these parts. 

Anasarca is not infrequent. It sometimes arises from obstructed circula- 
tion in consequence of compression of the thoracic vessels by enlarged 
lymphatic glands ; in other cases it is due to diminished plasticity of the 
blood, a result of the tubercular cachexia. The latter is the more common 
cause. It is not an important symptom, on account of the small amount of 
serous transudation and the character of the parts in which it occurs. 

Emaciation, already alluded to, is early, constant, and progressive. Under 
the age of six or eight months it is less marked than in older children, many 
preserving considerable rotundity of features and form even in advanced 
tuberculosis. The failure of the strength corresponds in amount and prog- 
ress with the emaciation. Slight at first, and exhibited only by a degree of 
lassitude, it gradually increases, till for weeks before death the little patient 
is fatigued by the ordinary muscular movements, and is inclined to be quiet. 

The nervous system is not ordinarily affected except in cases of intra- 
cranial tubercles. In acute tuberculosis or tuberculosis complicated by 
severe inflammation there may be agitation and delirium, especially at 
night. 

In most patients the mucous membrane of the buccal cavity presents its 
normal appearance, with the exception of a moist fur upon the tongue and a 
paler hue than normal of its surface generally. In acute tuberculosis and in 
cases complicated by inflammation the tongue is sometimes dry and brown. 
The appetite may be normal till the close of life or it is poor or changeable. 
Occasionally it is increased, although the disease is progressing. The bowels 
are regular or relaxed. Diarrhoea may be a prominent symptom, even when 
there are no intestinal tubercles or ulceration. Meteorism and fulness of the 
abdomen are common. 

Fever, constant, but usually with evening exacerbation, is rarely absent- 
It continues for weeks or months. During the exacerbation the pulse rises 
to 120, 140, or even to 180 beats per minute, and there is a corresponding 
exaltation of the temperature, which in the latter part of the day, without 
inflammatory complication, ranges from 100° to 102° or 103°. The febrile 
movement is a symptom of diagnostic value as regards the nature of the dis- 
ease, though it does not indicate the seat of the tubercles. 

In addition to the symptoms now described, there are special symptoms 
due to tuberculization of the different organs. In young children, on account 
of the fact already referred to — to wit, the tendency to a generalization of 
tubercles — there is often a blending of the symptoms which arise from dif- 
ferent organs, but with care it is not difficult in most instances to isolate and 
refer them to their proper source. The following are the symptoms which 
arise from tuberculization of the more important organs : 

Encephalon. — The symptoms produced by tubercles of the encephalon 
vary according to their seat and size and the structural changes in surround- 
ing parts to which they give rise. Meningeal tubercles, which are located 
for the most part in the meshes of the pia mater, and ordinarily along the 
course of the small arteries, are, as a rule, small, not more than a line in 
diameter, and they may remain latent for a considerable time. In the 
majority of cases, however, they sooner or later cause meningitis, the 
symptoms of which are well known and need not be described. But 
tubercles in this situation do sometimes give rise to symptoms when 
there is no meningeal inflammation. They occasion congestion of the sur- 
rounding vessels and serous transudation, and, if developed on the under 



TUBERCULOSIS. 215 

surface of the pia mater, they may produce symptoms by encroaching upon 
and irritating the brain ; for they are sometimes so much imbedded in the 
convolutions that careful examination is required in order to determine that 
they are meningeal and not cerebral. Among these symptoms may be 
mentioned headache, frontal or occipital, sometimes intermittent, nausea, 
melancholy, and in certain cases the symptoms produced by serous trans- 
udation. 

The symptoms of cerebral are in part similar to those of meningeal 
tuberculosis, but in most cases others of a neuropathic character are 
present, which serve for differential diagnosis. The differences as regards 
the symptoms of different patients having cerebral tubercles are attribut- 
able in part to their size and rapidity of growth, but more to the differ- 
ence in their seat ; for any part of the brain may be the seat of tubercles, 
though certain portions, as the cerebellum, are more frequently affected than 
others. 

The child with cerebral tubercles is quiet, but irritable, and easily excited. 
Delirium is not common, but many before the close of life exhibit a degree 
of mental dulness. The headache, common in cases of cerebral as well as 
meningeal tubercles, may be nearly general, or it is frontal, parietal, or occip- 
ital according to the seat of the tubercles. It is often lancinating, often 
intermittent. 

Clonic convulsions occur toward the close of life. Exceptionally, they 
are among the earliest symptoms. Observations have failed to establish any 
relation between the seat of the tubercles and the localization of the convul- 
sions. The convulsions may be unilateral, while the tubercles are in both 
hemispheres ; or general, while the tubercles are on one side only. 

The severity and duration of the convulsive attacks, and the frequency 
of their occurrence in tuberculosis of the brain, vary greatly in different 
patients. They have been attributed to softening of the cerebral substance, 
which sometimes occurs immediately around the tubercles, to local conges- 
tions excited by them, and also to serous effusions in the ventricles. The 
convulsions sooner or later end in paralysis or coma. 

Contraction, or tonic spasm of certain muscles, is sometimes observed. 
Its most frequent seat is in the muscles of the back and of one or both of 
the lower extremities. It is a late symptom. It occurs in those cases in 
which there is softening around the tubercles, and usually in the muscles of 
the opposite side. 

Paralysis is also a late, but not an infrequent, symptom. It is preceded 
by headache, and sometimes, as already stated, by convulsions. Occurring 
as a symptom of tuberculosis of the brain, it is due either to pressure on a 
cranial nerve or to compression and perhaps softening of the cerebral sub- 
stance. The paralysis may be paraplegic, commencing as feebleness of the 
lower extremities, and increasing until it becomes complete, or more or less 
complete, hemiplegia. In paraplegia due to tubercles of the brain the cere- 
bellum is, as a rule, their seat ; while paralysis of one side or of certain mus- 
cles of one side indicates tubercles of the opposite cerebral hemisphere ; but 
there are exceptions. Paralysis of the third cranial nerve gives rise to ptosis 
— of the sixth, to paralysis of the external motor nerves of the eye. and 
therefore to internal strabismus. 

Feebleness or loss of vision, inequality, oscillation, and finally dilatation 
of the pupils, are not infrequent symptoms of tuberculosis of the brain, and 
they possess great diagnostic value. Atrophy of the optic nerve, causing 
amaurosis, sometimes results from tubercles as well as other tumors of the 
brain. Atrophy of this nerve occurs not only when the tubercles are so 
located as to press on the optic tract, in which case the explanation is appar- 



216 CONSTITUTIONAL DISEASES. 

ent, but also, in certain patients, when the tubercles are in other parts of 
the brain. In these last cases it is thought by Brown-Sequard and others 
that the imperfect nutrition of the nerve is due to contraction of its nutrient 
vessels, produced by the tubercles through reflex action. 

In tuberculosis of the brain symptoms pertaining to the respiratory, cir- 
culatory, and digestive systems are either absent or are quite subordinate to 
those of a neuropathic character. Slowness of the pulse, with or without 
intermittence, has sometimes been observed, and it is therefore a symptom of 
some diagnostic value. Toward the close of life both pulse and respiration 
are usually accelerated. Vomiting, constipation, and retraction of the abdo- 
men, which are so common in meningitis, are only occasional symptoms. 

Bronchial Glands. — During the progress of tuberculosis, hyperplasia, 
cheesy degeneration, and softening of various lymphatic glands may occur 
throughout the body, but the bronchial and mesenteric are not only those 
which are most frequently affected, but they are the only glands, unless in 
exceptional instances, which materially increase the danger or give rise to 
special symptoms. These symptoms either have a mechanical cause — to wit, 
the pressure exerted by the enlarged glands on contiguous parts — or they are 
due to softening of the glands and consecutive inflammation and ulceration. 

The following are the principal symptoms due to compression ; some of 
them are not infrequent, others are rare : Compression of the pulmonary 
veins retards the flow of blood from the lungs to the left auricle, giving rise 
to congestion and, in extreme cases, oedema of the lungs, with sanguineous 
extravasation into the lung-substance, congestion of the right cavities of the 
heart, hepatic veins, and of the systemic capillaries generally. Compression 
of the pneumogastric nerve or of the recurrent laryngeal, which is the motor 
nerve of the laryngeal muscles, modifies the voice and produces a cough 
which is often spasmodic. The cough resembles that of pertussis, and has 
been mistaken for it, but it is not so violent or protracted. The voice, clear 
and natural at first, becomes by degrees hoarse or feeble from deficient in- 
nervation of the laryngeal muscles. 

An enlarged gland or mass of glands lying against the trachea or one of 
the bronchial tubes (this may occur with tubes up to the third or fourth 
division), and pressing its walls inward, obviously obstructs more or less the 
current of air. If there be considerable obstruction, a loud, sonorous rale is 
produced, which is heard distinctly at a distance from the chest, obscuring 
other rales. It is loudest when the patient is agitated, and it sometimes 
intermits. Feeble respiratory murmur, dyspnoea, and a cough are not infre- 
quent in bronchial phthisis. Diminished intensity of the respiratory murmur 
is general or partial, according to the seat of the compression. It has been 
most frequently observed at the summit of the lungs. In certain patients 
this symptom is not constant, the respiration being for a time feeble and 
then normal. The dyspnoea may be a prominent and distressing symptom, 
the alse nasi dilating, and the inframammary region sinking with each respira- 
tion. The cough which occurs when a gland presses on the trachea or bron- 
chial tube is due to the tracheitis or bronchitis to which the pressure gives 
rise. If ulceration occur at the point of pressure, the cough continues as 
long as the ulcer remains. Compression of the large veins within the thorax 
which return blood from the head and upper extremities causes more or less 
congestion of these parts, with, perhaps, transudation of serum in the sub- 
cutaneous connective tissue and within the cranium. Rarely, a softened 
gland by ulceration gives rise to other symptoms than those mentioned — to 
wit, hemorrhage by ulceration into a vessel or pleuritis or pneumonitis if the 
ulceration be toward the lungs. 

Improvement in the condition of the patient affected with bronchial 



TUBERCULOSIS. 217 

phthisis is not unusual. It may be permanent, but in most patients it is 
temporary, so that in a few weeks or months the symptoms are as severe as 
before. The improvement is due to softening and elimination of a gland 
which had given rise to symptoms by its mechanical effect or by the inflam- 
mation which it had excited. 

Physical Signs. — From Tubercular Bronchial Glands. — These are absent 
or obscure in the incipient disease when the glands are small, and they are 
most marked in those cases in which the glands are so large as to press on 
the thoracic walls, since they then become the medium for the transmission 
of sounds to the ear. The part of the thorax against which they most fre- 
quently press is the dorsal vertebrae from the first to the sixth, and each side 
of the vertebrae, and less frequently the upper third of the sternum. The 
physical signs are dulness on percussion over the interscapular space, and 
perhaps, though to a less extent, over the upper part of the sternum, and 
bronchial respiration in the same situations. Occasionally a bruit can be 
detected, due to the pressure of a gland on one of the large vessels of the 
chest. 

Lungs. — A cough is one of the earliest and most persistent of the symp- 
toms of pulmonary tuberculosis. It is so rarely absent that those of large 
experience do not meet with more than one or two such cases. It varies in 
severity and frequency. If the tuberculosis be acute, and its course rapid, 
the cough, even from its commencement, is frequent, so as to weary the 
patient and deprive him of needed rest. But in ordinary cases — that is, 
when the disease is chronic — it commences gradually, attracting at first little 
attention by its infrequency, but becoming more frequent and painful as the 
malady advances. 

Ordinarily, the cough is dry in the first weeks or months, but it becomes 
looser in the course of the disease, from the greater amount of bronchial 
inflammation. In exceptional instances it has a spasmodic character, like 
that produced by pressure of an enlarged bronchial gland on the pneumo- 
gastric or recurrent laryngeal nerve. This occurs from the accumulation of 
viscid mucus in one or more of the bronchial tubes, usually in dilated portions 
of them, from which it is with difficulty expectorated. 

The respiration in pulmonary tuberculosis is accelerated in proportion to- 
the degree of tuberculization. Tuberculization of a considerable part of both 
lungs gives rise to dyspnoea, especially when, as is ordinarily the case, bron- 
chial, pulmonary, or pleuritic inflammation has supervened. Pneumonitis or 
pleuritis gives rise to the expiratory moan, and as these inflammations, when 
induced by tubercles, are protracted, the symptom may continue for weeks 
or months. 

Patients under the age of six years do not expectorate, or but rarely. 
After this age expectoration is not common in the commencement of pul- 
monary tuberculosis, but in the confirmed disease it is a pretty constant 
attendant of the cough. Haemoptysis is also rare under the age of six years, 
and less frequent subsequently than in the adult. It is most likely to occur 
in those cases in which there is already passive congestion of the lungs pro- 
duced by the pressure of enlarged bronchial glands in the manner already 
described. Patients old enough to express their sensations, sometimes com- 
plain of fugitive pains under the sternum or between the shoulders. 

In young children the physical signs of incipient pulmonary tuberculosis 
are wanting, or are so obscure as not to be readily recognized. This is due 
to the small size and dissemination of the tubercles. In older children the 
physical signs appear early, and are readily recognized, because, as a rule, 
the tubercles are aggregated, and are more frequently at the apices of the 
lungs, as in the adult, than elsewhere. In the advanced disease, whether in 



218 CONSTITUTIONAL DISEASES. 

infancy or childhood, when inflammation and more or less destruction of the 
lung-substance have occurred, the physical signs, so far from being obscure, 
enable us, in most cases, in connection with the history, to make an immediate 
and positive diagnosis. 

In young children affected with pulmonary tuberculosis the irregular and 
imperfect expansion of the lungs produces by degrees changes in the shape 
of the thorax which are apparent on inspection. In some, the lungs being 
habitually imperfectly inflated, the obliquity of the ribs is increased, and the 
thorax consequently elongated, while its antero-posterior and transverse diam- 
eters are diminished. This obviously increases the convexity or arch of the 
diaphragm, so that this muscle sometimes lies against the thoracic walls as 
high as the ninth or even eighth rib. If the costal cartilages are yielding, 
there are anterior flattening of the chest and depression of the sternum ; if 
they are firm on account of the more advanced age, the chest remains circular. 

Another shape of the thorax is not infrequent in feeble tubercular chil- 
dren, especially infants, who have suffered from repeated attacks of bronchitis. 
It occurs also in the non-tubercular if the conditions which favor it are present. 
The conditions are, on the one hand, feebleness of the patient, with diminished 
force of respiration and impaired resiliency of the ribs, and, on the other, 
obstruction by mucus of one or more of the bronchial tubes. Occlusion, more 
or less complete, of a bronchial tube, and consequent obstruction to the current 
of air, produce a corresponding degree of collapse in the portion of lung to 
which the tube leads. The parts which collapse are, in most cases, the lower 
lobes and the thin anterior margins of the upper lobes. This causes lateral 
depression of the lower ribs, except such as are pressed outward by the 
abdominal viscera and an anterior projection of the lower part of the sternum. 
The shape of the thorax in these cases differs from that in rachitis in the fact 
that the lateral depression does not extend to the upper ribs, nor does the 
upper part of the sternum project. 

Certain precautions should be observed in examining the chest by percus- 
sion and auscultation. The child should sit or recline, with the arms and 
shoulders in the same position on the two sides, and the axis of the trunk 
straight. Inclination of the trunk to either side, raising or depressing a 
shoulder, may produce an appreciable difference in the two sides as regards 
the physical signs. Percussion of the two sides should be practised at the 
same stage of respiration. A slight difference in the degree of resonance 
does not afford proof of disease unless it be observed at different examina- 
tions ; for in feeble children it often happens that all portions of the lungs do 
not expand alike, so that where we have noticed slight dulness at one visit, 
it may by the next have disappeared, or even at the same visit, if forcible 
inspirations be excited. 

The physical signs ascertained by palpation, auscultation, and percussion 
are, as in the adult, vocal fremitus, bronchial respiration, bronchophony, and 
dulness on percussion. In those cases in which the tubercles are mainly at 
the apices of the lungs, diminished expansion of the infraclavicular region is 
observed during inspiration, and this part of the thoracic wall is permanently 
depressed, so that the clavicles are unusually prominent. If there be 
emphysema, this flattening does not occur or is slight. Dulness on percus- 
sion, though more frequently observed in the infraclavicular region than 
elsewhere, may be present in different isolated places. If pneumonia super- 
vene, the dulness not infrequently extends over a considerable part of one 
lung. The cracked-pot sound is often observed on percussion, but it pos- 
sesses little diagnostic value. It can be produced when there is no pul- 
monary disease by percussion over a bronchus. 

Bronchial respiration and bronchophony are important signs, as indicating 



TUBERCULOSIS. 219 

solidification of the lung, but they do not show whether the solidification be 
tubercular or pneumonic or the two conjoined. This must be determined 
by the history of the case, the extent of surface over which these signs are 
heard, and their persistence. When the tubercles begin to soften and the 
lung-tissue breaks up, moist rales appear, often hoarse and gurgling, obscur- 
ing the bronchial respiration. A cavity in the lung, or pneumothorax, is 
attended by the same physical signs as in the adult. 

Pleura.. — Little need be said in reference to the symptoms and physical 
signs of tuberculosis of the pleura, since this affection is in most instances 
associated with tuberculosis of the lungs, and is not distinguishable from it. 
But now and then the pleural tubercles are numerous and large, giving rise 
to symptoms, while those of the lungs are small, few, and without symptoms 
or attended by symptoms which are quite subordinate. Either the costal 
or visceral portion of the pleura may be the seat of tubercles. They are 
developed directly under the pleura or upon its free surface. They may 
occur in the newly-formed connective tissue which results from pleuritis. 
Those located upon the free surface or under the costal pleura rarely soften, 
while those under the visceral pleura sometimes soften and cause ulceration. 
Occasionally numerous aggregated tubercles form a firm continuous layer 
upon the surface of the pleura, preventing, if upon the visceral pleura, full 
expansion of the lung. This may give rise to a degree of dulness on per- 
cussion and feebleness of the respiratory murmur. Ordinarily, however, in 
this form of tuberculosis the symptoms and physical signs, so far as any are 
observed, are due to the pleuritic inflammation which the tubercles excite. 

Stomach and Intestines. — The symptoms in tuberculosis of the stomach 
and intestines vary according to the seat and stage of the tubercles. 

Tubercles, whether gastric or intestinal, are not at first accompanied by 
symptoms, or the symptoms are obscure and ill-defined. Symptoms arise 
when inflammation occurs in the tissues in which the tubercles are imbedded 
or upon which they lie, and through their irritating action. Diarrhoea is one 
of the most common and persistent of the symptoms. The alvine discharges 
are brown and thin, and sometimes, in advanced cases, very offensive. They 
may be streaked with blood which has escaped from the ulcers. Intestinal 
tubercles, developed immediately underneath the peritoneal coat, sometimes 
cause local peritonitis, usually of little extent. This gives rise to circum- 
scribed pain, tenderness, and more or less meteorism. 

Diagnosis. — It is evident from the foregoing description of symptoms 
that the diagnosis of incipient tuberculosis is much more difficult in children 
than adults. Before commencing the examination it is best to learn the 
hereditary tendencies of the family and the history of the patient, especiallv 
as regards antecedent disease or debilitating agencies, and the duration of 
the symptoms. 

Early and accurate diagnosis of tuberculosis in the child, as well as in 
the adult, is now rendered possible by the discovery of the tubercle bacillus 
in 1882 by Koch. This bacillus, abounding in the sputum as well as in the 
affected organs of phthisical patients, having a slender rod-like form, with 
a length varying from one-fourth to the entire diameter of the red blood-cor- 
puscles, and susceptible of a peculiar staining by the aniline colors which 
differentiates it from all other bacilli, is, as we have stated above, believed to 
be uniformly present in tuberculosis and absent in other conditions. 

Children with tuberculosis of the lungs expectorate comparatively little. 
but sufficient sputum can be obtained in most instances for the purpose o\! 
diagnosis. The presence of the bacillus indicates clearly the tubercular 
nature of the disease. 

Tuberculosis of the encephalon is diagnosticated with more difficulty than 



220 CONSTITUTIONAL DISEASES. 

that of the thoracic or abdominal organs ; but certain of these organs are in 
most patients tubercular at the same time, and the knowledge of the fact 
that they are affected aids in the diagnosis of the disease of the brain or its 
meninges. Among the symptoms of intracranial tuberculosis which possess 
diagnostic value may be mentioned cephalalgia and more or less fever, with 
exacerbations in the commencement of the disease, and, at a more advanced 
period, strabismus, inequality or irregular action of the pupils, impairment 
of vision, retraction of the head, and convulsive movements or paralysis. 

In certain cases careful observation and discrimination of symptoms are 
requisite in order to determine whether they arise from intracranial tubercles 
or from congestion of the brain caused by obstruction in the venous circu- 
lation by the pressure of enlarged bronchial glands. 

The diagnosis of bronchial phthisis, when the glands are still small, is 
necessarily uncertain, on account of the absence of symptoms. When they 
have increased in size and are so located as to press on the pneumogastric or 
recurrent laryngeal nerve, producing the spasmodic cough already described, 
the differential diagnosis between that disease and pertussis may be made by 
attention to the following facts : Bronchial phthisis occurs singly and is non- 
contagious, while pertussis occurs as an epidemic and with evidences of con- 
tagion. There are no successive stages — to wit, those of catarrh, paroxysmal 
cough, and decline — as in that disease, and the cough, though paroxysmal, is 
short and without whoop or vomiting. 

In feeble children with inherited tubercular diathesis, emaciation, sweats, 
a chronic cough, and the absence of pulmonary symptoms, should excite 
suspicions that the bronchial glands are involved. The evidence is almost 
conclusive if the cough become paroxysmal and there be a loud, persistent 
tracheal or bronchial rale. 

In certain patients affected with this form of tuberculosis we have seen 
that the prominent symptoms are due to compression of one or more of the 
large vessels in the chest. Compression of these vessels, and consequent 
retarded circulation, may be confidently referred to enlarged bronchial glands, 
since aneurism, carcinomatous or other tumors, which w T ould produce a sim- 
ilar result, are very rare before puberty. Sometimes the diagnosis is rendered 
certain by the physical signs observed by auscultation and percussion over 
the sternum and the interscapular space. The condition of the external 
glands should also be observed, as those of the axilla, neck, and groin. 

The diagnosis of pulmonary, though more readily made than that of 
intracranial and bronchial, tuberculosis is often difficult and uncertain. This 
is in part explained by the fact that the tubercles are so frequently dis- 
seminated, while emaciation and a chronic cough are not infrequent from 
other causes than tubercles. Rachitis, intestinal worms, dentition, simple 
tracheal or bronchial inflammation, may be attended both by a chronic cough 
and emaciation. Caution is therefore requisite in order to avoid a grave error 
in diagnosis. Precipitancy in the diagnosis of doubtful cases is worse than 
indecision, and it is often best to postpone an expression of opinion as to the 
nature of the disease till the case has been observed a few days. 

The significance and importance of the symptoms, physical signs, and 
other facts on which a diagnosis must be based have already been sufficiently 
pointed out. It is difficult — in fact, in certain cases impossible — to discrim- 
inate by the physical signs between simple cheesy pneumonia and cheesy pneu- 
monia which has ended in the formation of tubercles. The patient has an 
attack of catarrhal pneumonia, but instead of absorption of the inflammatory 
product, cheesy infiltration occurs, and the lung in places becomes infiltrated 
with pus, softens, and breaks down. The patient presents the symptoms and 
physical signs of phthisis. He may recover after a protracted sickness or 



TUBERCULOSIS. 



221 



Though 



Fig. 39. 



the differ- 




Bacilli of tubercle from sputum. 
X 500 (Bristowe). 



may die. But cheesy degeneration of the inflammatory product com- 
monly ends in the development of tubercles, and in a certain proportion 
of cases tubercles do form in the last weeks of life, 
ential diagnosis in such cases between cheesy 
pneumonia and tuberculosis supervening on 
pneumonia is impossible by the physical 
signs, practically the discrimination is unim- 
portant, as the same treatment is required. 
But it is obvious, from the facts now ascer- 
tained in reference to the tubercle bacillus, 
that in all cases of doubtful diagnosis the 
sputum, if it can be obtained, should be ex- 
amined microscopically. If the bacillus be 
present, the diagnosis of tubercular disease 
may be considered certain. 

Prognosis. — It has long been the belief 
in the profession, as well as among the laity, 
that tuberculosis is in the end, with few ex- 
ceptions, fatal, whatever remedial measures 
are employed, and that, therefore, remedies 
may ameliorate symptoms, but do not change 
the result. But since attention has been 
directed to this subject a sufficient number of observations have been made 
to show that tuberculosis at an early stage can in a considerable number 
of cases be cured or rendered latent. The late Professor Austin Flint, in 
his treatise on Phthisis, published in 1875, stated that of 670 phthisical 
cases which came under his observation, he ascertained by auscultation and 
percussion that the disease had been cured in 44 and was non-progressive in 
31 others. But the most convincing proof of the curability of tuberculosis 
is furnished by the post-mortem examination of those who died of other dis- 
eases. A cretaceous or fibroid state of the apex of the lung, without tuber- 
cles elsewhere, may be regarded as certain evidence of arrested tuber- 
culosis. Now, two of the curators of large New York hospitals inform me 
that they frequently find cretaceous or fibroid degeneration at the apex of 
the lung, without tubercles elsewhere, in the autopsies in these institutions. 
One of these gentlemen, whose examinations are in the dead-house of Belle- 
vue Hospital, states that this evidence of arrested tuberculosis is present 
in at least one-fourth of the cadavers which he examines. The Bellevue 
Hospital patients come from the most crowded and insalubrious tenement- 
houses of the city, and have led a life of poverty and privation, and fre- 
quently of dissipation. H. P. Loomis (Med. Record, Jan. 9, 1892) gives the 
following results of post-mortem examinations made in the Bellevue dead- 
house. Of 769 dying of non-tubercular diseases, 71, or over 9 per cent., had 
the anatomical characters of a cured tuberculosis. The London Lancet 
(September 22, 1888) states that M. Vibert has examined the records of 
the necropsies in the Paris Morgue, and that in 131 subjects who had died 
suddenly from violence or acute diseases, the lesions of pulmonary tuber- 
culosis were present in 25, and in 17 of these the tubercles had undergone 
the cretaceous or fibroid change, and were practically cured, h is certain, 
therefore, that tuberculosis in its commencement, and when affecting only 
a small portion of the lung, is often cured or rendered permanently latent. 

It is now known that ordinary serum circulating in the blood-vessels 
possesses marked germicidal properties, and therefore measures which benefit 
the general health and improve the quality of this important constituent of 
the blood have a curative effect as regards tuberculosis. The tubercle bacillus 



222 CONSTITUTIONAL DISEASES. 

is an irritant to the tissues, and in cases which are cured or rendered latent it 
becomes surrounded by dense tissue which in time undergoes the cretaceous 
or fibroid degeneration. The bacilli in the interior of the mass may retain 
their vitality for an indefinite time, but, being encapsulated, they do no harm. 
There can be no doubt that many adults have local tuberculosis, and are cured 
by improvement in their general health and in the quality of their blood, 
without suspecting that they have had this disease. In young children, 
especially in infants, tubercles are frequently disseminated in the organs, 
and recovery under such circumstances must be impossible or rare ; but local 
tuberculosis or tuberculosis limited to certain glands, as the bronchial, is not 
unusual in childhood, and this form of the tubercular disease may be cured 
by measures which improve the general health. 

Hospital statistics show that the average duration of the disease is from 
three to seven months. Under favorable circumstances it is more protracted,, 
even to two or three years. Those succumb soonest who inherit a strongly- 
marked tubercular diathesis, live in damp, dark, and ill-ventilated apartments, 
and whose diet is scanty or of poor quality. Therefore in the poor quarters 
of the city tuberculosis presents a worse form and pursues a more rapid course 
than among families in better circumstances. 

Favorable prognostic signs are absence of tubercular diathesis, good 
appetite and general health, with little emaciation, infrequency of cough, 
with respiration, pulse, and temperature nearly normal. Such symptoms may 
afford hope of recovery with judicious regiminal and therapeutic measures. 
On the other hand, if the symptoms be grave death is inevitable, unless in 
bronchial phthisis, in which, even when there is considerable urgency of 
symptoms, the offending gland is sometimes eliminated by softening and 
ulceration, and the patient improves temporarily, if he do not ultimately 
recover. Complete and permanent recovery is, however, quite exceptional in 
bronchial phthisis, as it is in other forms of the disease. As Liebermeister 
has said, recovery in any form of tuberculosis is impossible except in incipient 
and very limited forms of the disease. 

Death in tuberculosis of children may occur from exhaustion induced by 
the general disease or from the local effects of the tubercles. Thus, in intra- 
cranial tuberculosis it may result from meningitis ending in convulsions and 
coma ; in pulmonary tuberculosis, from dyspnoea, though more frequently 
from exhaustion ; in that of the bronchial glands, from dyspnoea or hemor- 
rhage ; in that of the abdominal organs, from peritonitis or protracted diar- 
rhoea. 

Prophylaxis. — Since tuberculosis originates in so many different ways, 
measures designed to prevent this disease have a wide range. Precau- 
tionary measures are especially required in the nursing of the tuberculous 
patient. His sputum should always be received in a cup or spittoon contain- 
ing a disinfectant liquid, and this vessel when emptied should be cleansed 
with boiling water or a disinfectant. Sputum should never be received upon 
a handkerchief or cloth and allowed to dry. Towels and handkerchiefs should 
be moist when used, and immediately afterward placed in boiling water or a 
disinfectant. We have seen what disastrous results occur from the dried 
sputum. Whatever may be said of the innocuousness of the breath of the 
phthisical patient, based on the supposition that the tubercle bacillus has so 
great a specific gravity in its moist state that it is not exhaled in ordinary 
respiration, nevertheless the sad experience of the midwife related in a fore- 
going page should teach us to avoid the breath of a consumptive so far as is 
compatible with proper ministrations to him. The floors and walls of his 
apartment should occasionally be washed with a disinfectant fluid, and the 
bedding, clothing, rugs, and mats should never be shaken in the apartment, 



TUBERCULOSIS. 223 

but outside the house. Ventilation of the apartment should be allowed to 
the full extent compatible with the safety of the patient. The remedies 
which we will hereafter recommend in the treatment of the patient are 
destructive to the bacillus, and therefore whenever employed have also a 
prophylactic action. 

No physician who has read in the medical journals of the last decade the 
many reports of cases in which milk has been the vehicle of pathogenic 
organisms has failed to see the urgent need of obtaining this indispensable 
article from healthy dairies. Families should insist on the inspection at 
regular intervals of the dairies that furnish them milk, and the exclusion of 
such animals as exhibit the least sickness. Moreover, no one with a chronic 
cough should be employed in milking or in the subsequent handling of the 
milk. To this matter we have already called attention. But with the utmost 
endeavor, on the part of families living at a distance, to obtain milk free from 
impurities, no one can state positively that it will not sooner or later contain 
pathogenic organisms, as those of diphtheria, scarlet fever, typhoid fever, or 
tuberculosis, so many and unsuspected are the modes of infection. Fortu- 
nately, heat at or near the boiling-point is an effectual sterilizing agent, and 
it can be employed without diminishing the nutritive properties of milk or 
rendering it more indigestible. I do not forget the interesting experiments 
which have been made to determine the tenacity of life of the tubercle 
bacillus when subjected to heat and cold. In experiments made it is said 
to outlive most of the microbes associated with it. Schill and Fischer state 
that dried and pulverized tubercular matter not subjected to treatment 
retains its virulence six months, and Pietro states that tubercular sputum 
well dried and maintained at 77° retains its virulence nine or ten months. 
But what concerns us most at present is the remarkable statement made by 
Max Voelsch (Centralb. fur Min. Med., June 30, 1888), that twice boiling- 
does not entirely destroy the virulence of the tubercle bacillus. I habitually 
direct that the morning supply of milk designed for children shall be imme- 
diately placed in a steamer and subjected for fifteen minutes to a temperature 
of 167°, the temperature which, according to Pasteur, is sufficient to destroy 
the pathogenic germs. No pathogenic microbe can probably survive if sub- 
jected so long a time to this degree of heat. The flesh of the tubercular 
animal, which it is believed is often purchased by unsuspecting families, 
evidently requires similar treatment — that is, thorough cooking — in order to 
be rendered innocuous. A competent meat inspector should be employed at 
each slaughter-house, and all diseased meats be rejected ; but in the present 
management of the meat market the only sure method of preventing the 
presence of living and active bacilli in the meat foods appears to be by 
thorough cooking. 

Outdoor life, residence in elevated localities, where the air is not only 
pure but rarefied, the occupancy of sunlit and well-ventilated rooms, the 
avoidance of rooms or localities where the air is contaminated by the pres- 
ence of others, as in crowded schools or factories, or by unwholesome occu- 
pations, and all measures which promote the appetite and general health, are 
prophylactic, as they are also to a certain extent curative, of tuberculosis. 
It is evident, from what has been stated above, that caseous substance occur- 
ring in any part of the system, inasmuch as it sustains a close causal relation 
to tuberculosis, should, if practicable, be removed by surgical measures. 
Moreover, since cheesy degeneration results for the most part from inflam- 
mations occurring in the scrofulous, measures designed to prevent or cure 
such inflammations or to cure scrofula have a prophylactic effect as regards 
tuberculosis. The strumous child should be watched with great care, and 
such measures be employed as are calculated to invigorate his system, lie 



224 CONSTITUTIONAL DISEASES. 

should receive antistrumous treatment, both hygienic and medicinal. Espe- 
ciall} T should glandular hyperplasia and the products of inflammation, whether 
occurring in the lungs or elsewhere, be, if possible, removed before caseation 
occurs. For this purpose the old remedies, like cod-liver oil and syrup of 
the iodide of iron, given internally, and for hyperplasia of the subcutaneous 
glands ointments like iodide of potassium in lanolin, may be advantageously 
employed. Finally, one having an abrasion or sore of the cutaneous or 
mucous surface, or catarrh of the air-passages, as indicated by discharge 
from the nostrils, sore throat, or a cough, should not attend as nurse or 
otherwise a phthisical patient until his local ailment is cured, since the tuber- 
cle bacillus is believed to enter the system more readily through a diseased 
than a healthy surface. 

Treatment. — The indications of treatment are twofold : first, to invigorate 
the system in every possible way, so that the organs and tissues are in a better 
condition to resist the bacillus and the serum to antagonize and destroy it ; 
and, secondly, the employment of medicinal agents, if such can be found, 
which are destructive to the bacillus and safe to the patient. 

Measures designed to improve the general health must be chiefly hygienic, 
and are described in the text-books. The diet should consist of sterilized 
milk, the meat preparations, and farinaceous substances, prepared in such 
a way that they afford the maximum amount of nutriment and are easily 
digested. If the digestion be poor, peptonized food may be advantageously 
employed, and pepsin may be taken with the food. In 1881-82, Debove 
recommended gavage or forced feeding of consumptives through a flexible 
rubber tube having a funnel attachment, the tube being introduced into the 
stomach. He employed meat preparations, with pepsin. In the Medical 
Neics, October 1, 1887, Dr. S. Solis-Cohen of Philadelphia also recommended 
gavage in the treatment of phthisis. A quart of milk, two tablespoonfuls 
of beef powder, three eggs, fifteen grains of scale pepsin, and thirty drops 
of dilute muriatic acid were warmed and administered twice daily through 
a stomach-tube, a patient eating what he wished in the interval. Gavage 
has been employed by certain European physicians in the treatment of chil- 
dren suffering from various forms of innutrition, and it seems probable that 
tubercular patients may be benefited by it in some instances. In the ordi- 
nary mode of feeding, the predigested foods can often be used with benefit 
by consumptives, inasmuch as they have, for the most part, feeble digestion. 

As regards the hygienic measures designed to arrest tuberculosis, the 
most important, next to the use of proper food and the employment of such 
aids to nutrition as cod-liver oil and the alcoholic preparations, is outdoor life, 
and, if possible, in localities having a high altitude. The late Professor Flint, 
in examining the records of 62 cases of arrested phthisis which came under 
his observation, ascertained that the principal agent in effecting this result 
was exercise in the open air. He therefore strongly recommended this mode 
of life to consumptives, and also constant ventilation of their sleeping apart- 
ments, even in the winter season, the danger of taking cold being averted by 
maintaining sufficient warmth of air by a fire. Dr. James Blake has also 
reported instances of recovery of phthisical patients who lived during the 
five or six months of the dry season in the open air upon the Coast Range 
of mountains in California at an altitude of 3000 to 5000 feet. These 
patients were in the open air night and day, without even the protection 
of tents. 

Residence at a High Altitude. — The London Lancet, May 26, 1888, contains 
the abstract of a paper read before the Medico-Chirurgical Society of London 
by Dr. Williams, recommending residence at a high altitude as an efficient 
means of checking the progress of tuberculosis. He states that of 141 



TUBERCULOSIS. 225 

patients who had employed the high-altitude treatment, 14.13 per cent, were 
completely cured, 29.78 per cent, were much benefited, 11.34 per cent, were 
more or less benefited, and 17.02 per cent., including 13.47 per cent, who died, 
continued to grow worse. Drs. Quain and Pollock, in discussing this paper, 
expressed the opinion that consumptives who improve at a high altitude 
improve equally with the same treatment at lower elevations ; in other words, 
that residence at a high altitude does not influence the result. Brehmer, 
on the other hand, believes that the inhabitants have immunity from 
tuberculosis at an altitude of 1500 feet in Germany, of 4500 to 5000 feet 
in Switzerland, and 10,000 to 15,000 feet at the equator {Die Therapie 
Chronische Lungenbesclucerden, Wiesb., 1887). The most apparent and notable 
peculiarity in the air at high elevations, apart from its purity, is its rarefac- 
tion. At an altitude of 9000 feet above the level of the sea it is said, from 
observations made, that the air is so rarefied that three times the usual 
exercise of the lungs is required to meet the demands of the system. Dr. 
Mays states in a paper published in the Medical News, November 27, 1886, 
that the Quichua Indians, on the lofty plateaus of Peru, constantly breath- 
ing a rarefied air, " acquire enormous dimensions " of the chest, due to an 
increase in the size, and perhaps number, of the air-cells. More numerous 
and more exact observations are required in order to determine whether or to 
what extent residence at a high altitude is beneficial to consumptives, and, 
if it exerts a controlling effect on the disease, whether this result is due to 
the increased pulmonary expansion and activity or to other causes. Certainly, 
from observations already made, we are justified in recommending outdoor 
life in a mild and equable climate, and also residence at high elevations if the 
cold is not too severe. 

Residence in the Evergreen Forests and the Use of Turpentine. — In a paper 
read before one of the societies, and subsequently published, the late Dr. A. 
L. Loomis stated his belief that the terebinthinate vapors in the evergreen 
forests possess healing properties for consumptives. He quotes the state- 
ment of Ringer, that turpentine employed as a medicine enters the blood, 
and may be detected in the breath, the perspiration, and in an altered form 
in the urine of the patient. The presence of the vapor of turpentine in the 
pine forest, Dr. Loomis remarks, cannot be doubted, and its " local and con- 
stitutional effects," he adds, " are those of a powerful germicide as well as 
stimulant." Dr. Loomis quotes the opinion of Mr. Kingsett that turpentine, 
during its oxidation, evolves the peroxide of hydrogen, and therefore by the 
" oxidation of the terebinthinates there is produced in extensive pine forests 
an almost illimitable amount of peroxide of hydrogen, which renders the 
atmospheres of such forests antiseptic." He believes that the peroxide of 
hydrogen so abundantly produced in pine forests " successfully arrests putre- 
factive processes and septic poisoning," and therefore he recommends resi- 
dence in the pine forests as one of the most efficient means of relieving the 
symptoms of tuberculosis and retarding the progress of this fatal malady. 
At high altitudes the coniferous or evergreen trees usually predominate, and 
if the views of Professor Loomis be substantiated by future investigations. 
it. may be that the benefit believed to be obtained by consumptives at high 
elevations is partly due to the exhalations from these trees. 
, The bacteriologists who have cultivated the tubercle bacillus, and 
observed the action upon it of the various agents which have been employed 
and extolled by clinical observers, state that most oi' these agents do not 
penetrate the tubercular mass — that while they may destroy the superficial 
bacilli, they do not affect those more deeply seated, and therefore fail to 
arrest the disease. But turpentine and its derivatives appear to penetrate 
the tissues as deeply as almost any other agent, and therefore, it' they are 

15 



226 CONSTITUTIONAL DISEASES. 

sufficiently antiseptic and not too irritating, we may expect good results 
from their judicious use. But it is probable that they are less efficient as 
germicides than some of the other agents which can be safely employed, and 
therefore should be recommended only as adjuvants, or as remedies which 
may give some relief to the catarrhal and other symptoms without exerting 
any marked antiseptic action. Hohnfeld states that he applied oil of turpen- 
tine to fresh colonies of the micrococcus prodigiosus and staphylococcus 
aureus, and that it exerted little destructive or retarding effect on these 
micro-organisms. 1 These experiments would lead us to distrust the germi- 
cide action of turpentine and the terebinthinate preparations in tuberculosis, 
for the tubercle bacillus is tenacious of life beyond most other microbes. 

Dr. Trudeau of Saranac Lake prescribed the hot-air treatment in four cases 
four hours each day, the temperature of the inhaled air being 392° F. The 
first and second patients improved slightly at first, but refused the treatment, 
the one after one month, and the other after six weeks. The third patient 
was treated three months without the least appreciable effect. The fourth 
patient was treated four months, with manifest improvement in her physical 
signs and general health, but no more improvement than frequently occurs 
from any new mode of treatment. In all the cases the sputum was examined 
before, during, and after the treatment, and in every examination the tuber- 
cle bacillus was present. The result claimed for the hot-air treatment had 
not been obtained — that is, the destruction of the bacilli ; and if they are 
not destroyed in the sputum, certainly they are not in the tissue of the lung. 
Therefore there can be little doubt that the hot-air inhalations, so far from 
coming into general use, will be discarded, not only because they are 
unpleasant to the patient, but are inefficient. There is always a large amount 
of residual air in the alveoli, and there can be little doubt that in the hot-air 
inhalations the air in the alveoli and terminal bronchial tubes never attains 
the elevation of temperature of the air that is inhaled, nor of that which 
is exhaled. Moreover, as we have seen, the tubercle bacillus resists the 
destructive action of high temperature. It is said to retain its vitality 
in liquids which have been twice heated to the boiling-point. 

Creasote. — Of the many medicines which have been recently employed 
in the treatment of tuberculosis, creasote appears to have given more general 
satisfaction than any other. It has to a great extent taken the place of cod- 
liver oil, which was formerly employed in the treatment of tuberculosis in 
want of a better agent. I am informed that the late Dr. Cammann, the in- 
ventor of the binaural stethoscope, employed it twenty years ago in the treat- 
ment of tuberculosis, but it was seldom prescribed for this disease until 
within the last decade. In the Berliner Mimsche Wochenschrift, July 20, 
1886, Von Brunn stated that he had treated 1700 phthisical patients in the 
preceding eight years with creasote, giving to adults not less than six to eight 
drops in twenty-four hours. He employed it in solution with tincture of 
gentian and wine, and believed that he obtained good results, especially in 
acute unilateral cases. Professor Sommerbrodt stated in 1887 that he em- 
ployed creasote in about 5000 phthisical cases during the preceding nine 
years. At first he used Bouchard's solution of creasote, and afterward gel- 
atin capsules, each containing three-fourths of a grain of creasote and three 
minims of the balsam of Tolu. The amount of creasote administered daily 
to the patients who were adults was increased gradually from one capsule to 
not less than nine. As many as 600 to 2000 capsules were given to each 
patient without a break. In many cases the improvement was marked, not 
only in the symptoms and in the general health, but also in the physical 
signs. He believes that he has cured cases by insisting on a continuance of 

1 Fortschritte der 3Iedicin, October 1, 1887. 



TUBERCULOSIS. 227 

the treatment. To show the good effect of creasote, he cites the case of a 
student of sixteen years, with tuberculosis of the right lung, who took three 
capsules three times daily, or about seven and a half grains per diem. His 
cough abated, his weight increased six pounds in two months, his expectora- 
tion had ceased. Instead of the dull percussion sound over the apex of the 
right lung, only a slight rhonchus was observed, and his general health had 
greatly improved. 

Many others who have employed creasote during the last two or three 
years, both in this country and in Europe, report favorable results. Strum- 
pell says that it produces no ill effects, and in large doses it frequently causes 
improvement in such symptoms as the cough, expectoration, and appetite, but 
he doubts whether it exerts any marked curative effect upon the disease. It 
has been employed largely in the New York Hospitals and in family practice 
in various combinations, and the general opinion expressed is very favorable 
to its use. 

I have prescribed creasote for internal use in the following formula : 

R. Creasoti (Morson's), 
Spiriti chloroformi, 
Alcoholis, da. 3SS. — M. 

Dose for an adult, nine drops three times daily in half a teacupful of water con- 
taining a tablespoonful of brandy or two tablespoonfuls of wine. 

The nine drops of the mixture, containing three of the creasote, have been 
increased to twelve drops, or four of creasote, and thus far in my practice 
patients believe that they have been benefited by this remedy, and have 
desired to continue it. At the same time, in some instances I have recom- 
mended the inhalation of ten or fifteen drops of the same mixture from 
Robinson's inhaler. This dose of creasote, three or four drops, may seem 
large, but it is tolerated when sufficiently diluted, though it may be best to 
commence with a smaller quantity. Children should of course take doses 
proportionate to the age, the fractional part of a drop being sufficient for in- 
fants. Creasote has also been injected into the tubercular lung through the 
chest-walls by several physicians, a syringe provided with a long and delicate 
needle being used. Rosenbusch injected eight drops of a 3 per cent, solu- 
tion of creasote in almond oil in two places at the seat of the disease, or six- 
teen drops in all. The result was a marked diminution of the cough, the 
sweats, the amount of sputum, and, in recent cases, an increase in weight. 
The beech creasote was used, and the skin and apparatus were first sterilized 
by an antiseptic lotion. When the instrument was not introduced deeply 
enough, a sharp, pleuritic pain sometimes occurred, but it soon abated. 
Creasote appears to be the most valuable of the recent remedies recommended 
for tuberculosis, but in order to determine its exact value, the proper mode 
of employing it, and the size and frequency of the dose, more extended 
observations are required. Frantzel says that experiments have shown that 
this substance is inimical to the growth of the bacillus when mingled in 
minute quantity with a gelatin culture-medium, and on this fact is based its 
internal administration. When it is injected into the lungs through the 
chest-walls, Dr. E. G. Janeway of New York believes that it is very import- 
ant that the almond oil or other vehicle employed should be first sterilized. 

In the present state of our knowledge of the use of antiseptics in the 
treatment of tuberculosis, creasote is the one which is most deserving o'l con- 
fidence and employment. In New York City, in cases of protracted broncho- 
pneumonia with emaciation, the symptoms indicating the probability of 
cheesy degeneration and commencing tuberculosis, I am prescribing the 
hourly inhalation of the vapor of creasote, one part to ten of fifteen of tere- 



228 CONSTITUTIONAL DISEASES. 

bene, fifteen to twenty-five minims, or more of the mixture being dropped 
on the sponge in Robinson's perforated zinc inhaler. Children willingly in- 
hale this vapor five or ten minutes at a time, with some apparent relief of 
symptoms. 

Dr. Robinson (Amer. Journ. of Med. Sci.) writes : " I am convinced from 
what I have seen .... that we have in beechwood creasote a remedy of 
great value in the treatment of pulmonary phthisis, particularly during the 
first stage. Not only does it lessen or cure cough, diminish, favorably change, 
and occasionally stop sputa, and relieve dyspnoea in very many instances, but 
it also often increases appetite, promotes nutrition, and arrests night-sweats." 
Von Brunn obtained favorable results from the use of creasote in 1700 cases. 
The gastric digestion, and later the respiratory symptoms, were improved. A 
diminution, and even disappearance, of bacilli occurred. The creasote was 
given in wine and by inhalation. 

The experiments of Guttmann show that the tubercular bacillus will not 
grow in solutions of the strength of 1 : 2000, and only feebly in solutions of 
the strength of 1 : 4000. The medical journals during the last five years 
contain numerous communications recommending creasote as the most effi- 
cient remedy in tuberculosis and chronic catarrhs. For such maladies it has 
to a great extent taken the place of the old remedy, cod-liver oil. Seitz pre- 
scribes it for these affections with cod-liver oil, in the following formula : 

R. Creasoti, 38 grains (2.5 grammes); 

Olei morrhuse 6 \ ounces (200 " ); 

Sacchari, 2 grains (0.13 gramme). 

Dose : One to four teaspoonfuls two or three times daily. 
For children smaller doses. 

Creasote has also been given in two or three teaspoonfuls of orange juice, 
to which the same quantity of Tokay or Malaga wine is added, and it should, 
in my opinion, always be given, especially to children, in smaller and more 
frequent doses than most formulae state, and after the feeding, so as not to 
irritate the stomach. It is the common and, I believe, correct practice to pre- 
scribe the minimum dose at first and gradually increase the quantity given if 
tolerance is manifested. A half-drop to one drop after taking food would 
be considered a proper dose for a child of five years. But the dose can be 
doubled if sufficiently diluted so as not to be irritating, and given more times 
daily. 

Every year since the introduction into practice of creasote as a remedy 
for tuberculosis its use has extended and it has been more and more extolled. 
It is commonly stated by those who have most employed it, that creasote 
properly administered does no harm, but improves the digestion and general 
health ; therefore it has been useful when its vapor is employed in protracted 
catarrhal affections and tuberculosis, of the lungs and air-passages. By my 
own experience I can highly recommend the following formula : 

Creasoti (Morson's beechwood), £ij ; 

Terebene, *^iv. — Misce. 

Add one teaspoonful to three or four tablespoonfuls of boiling water, and 
inhale the vapor from three to five minutes, or employ the same upon the 
sponge of Robinson's perforated zinc inhaler. It may be used once in three 
or four hours or oftener. 

Guaiacol. — This is described in the books as a liquid compound consisting 
of 60 to 90 per cent, of creasote. In 1891-92 a carbonate of guaiacol was 
produced, which promises to be a medicine of great value, and in some 



TUBERCULOSIS. 229 

instances a substitute for creasote. It occurs in the form of neutral crystals 
without taste or odor, insoluble in water, but dissolving at 86° to 90°. The 
combination with the carbonate appears to remove all irritating properties 
from the medicine, and I have several times allowed five grains of the guaia- 
col carbonate to dissolve in my mouth and be swallowed without experiencing 
the least irritation from it. I look for a favorable reception of this agent in 
chronic catarrhs and in incipient as well as in advanced tuberculosis. 

As is the case with all common and fatal diseases, many new drugs for 
phthisis have been recommended each year since the appearance of the last 
edition of this book. Most of them, after a few trials, have fallen into disuse. 
The one that has attracted the most attention, originating from a high scien- 
tific authority, is tuberculin. 

Tuberculin. — Koch published the experiments which led to the preparation 
of tuberculin in the Deutsch. med. WocJien., No. 46, 1890. If a healthy guinea- 
pig be inoculated with a pure culture of the tubercle bacillus, the wound 
closes and for a few days appears to be healing. In about two weeks, how- 
ever, a hard nodule forms, which soon breaks down, leaving an ulcer until 
the death of the animal. But if the animal, successfully inoculated four to 
six weeks previously, be reinoculated, no nodule is formed, but on the second 
day the point of inoculation becomes hard and darker to the extent of .5 to 1 
centimetre. This dark necrotic substance is cast off and the wound soon 
heals. If the injection of a proper quantity be repeated in one to two days, 
the health of the animal improves and the wound becomes smaller, cicatrizes, 
and the lymphatic nodules diminish in size. Koch found, however, that 
" the objection to the use of the sterilized cultures lay in the fact that the 
dead bacilli were not absorbed, but remained at the point of injection, and 
caused more or less suppuration. The material which had a curative effect 
was something which was soluble and which entered the fluid of the tissue 
about the bacilli.'' Koch then endeavored to extract from the cultures of 
the bacillus this soluble substance. 

Clinical results are the test of the value of a medicine given to check or 
cure disease, and the result of the use of tuberculin, whatever will be its 
future, has been less efficient than that of creasote. Still, already one im- 
portant benefit has resulted from its use. If tuberculin be injected under 
the skin of an animal having tuberculosis, it causes fever, but none if the 
animal is healthy. It is therefore very useful as the means of excluding 
diseased cows from a dairy. 

I have described in the foregoing pages the most important of the remedies 
which have been recently recommended by apparently competent observers. 
There are others which, from their nature and the limited trial which they 
have received, I have not thought of sufficient importance to require notice. 
Most of them will probably soon be discarded by those who now recommend 
them. The hygienic measures — as outdoor life, residence at a high altitude. 
free ventilation of sleeping apartment, and the use of the most nutritious and 
easily-digested food — still maintain a most important place in the treatment 
of tuberculosis. Of the medicines, creasote, used internally and by inhala- 
tion, appears to be the most deserving of recommendation. 



230 CONSTITUTIONAL DISEASES. 

CHAPTER IY. 

SYPHILIS. 

Syphilis in infancy and childhood occurs under two forms — to wit, the 
congenital and acquired. The former is the more frequent. 

Etiology. — Congenital syphilis may be derived from either father or 
mother. Either parent, having syphilis in its first or second stage, may 
transmit it to the offspring, although at the time free from syphilitic symp- 
toms. The mother, healthy at the time of conception and contracting syph- 
ilis prior to the eighth month of gestation, may communicate the disease to 
the foetus. Syphilis contracted by the mother in the eighth or ninth month 
of gestation is less likely to be communicated to the foetus. Writers mention 
the case reported by Zeissl, in which the wife, previously well, contracted 
syphilis from her husband between the fifth and seventh months of gestation, 
and the infant, born at term, soon exhibited the characteristic syphilitic 
lesions. If both parents have syphilis at the time of conception, the infant 
is almost necessarily syphilitic ; on the other hand, if only one parent be 
syphilitic, the infant may or may not be contaminated. Sometimes with such 
parentage a part of the children are syphilitic and a part healthy. 

All syphilographers agree that syphilis in its third stage is not transmis- 
sible from parent to child, but parents in this stage of the disease are likely 
to beget scrofulous children. Hutchinson of London regards syphilis as an 
exanthem, with its periods of efflorescence and decline, and the symptoms 
and .ailments which characterize the so-called third state he regards as 
sequelae. That syphilis is no longer transmissible after the close of the 
second stage is shown by many observations. Thus, M. Mireur relates the 
history of a man and wife who were syphilitic and were never treated, but 
their children were without syphilitic symptoms. 

Acquired syphilis in infancy and childhood may be received through 
primary lesions — that is, by reception of the virus from a chancre or bubo — 
or it may be derived from certain of the secondary lesions. Inoculation by 
primary lesions may occur at the birth of the infant from a syphilitic sore in 
the vagina or upon the vulva of the mother ; inoculation in this manner is, 
however, rare. Children may also receive the virus from primary lesions on 
the persons of nurses or companions. Infection in this manner is sometimes 
accidental and sometimes the result of criminal conduct. A chancre on the 
breast of the wet-nurse not very infrequently communicates syphilis to the 
nursling. 

The contagiousness of " secondary manifestations," for a long time doubted, 
is now fully established. Syphilis may be communicated by the secretion or 
exudation of a mucous patch or a secondary sore. Hence the danger of 
suckling by infected wet-nurses, though they present no symptoms of recent 
syphilis. Excoriations or sores upon the nipple or breast of a syphilitic wet- 
nurse may communicate the disease to the nursling ; and, on the other hand, 
mucous tubercles or fissures upon the lips or tongue of the infected infant 
may be the means of contaminating a healthy wet-nurse. Many such cases 
are now contained in the records of medicine. Vaccination by means of the 
scab is also a mode by which syphilis has been communicated. (For further 
particulars in reference to this subject the reader is referred to our remarks 
on vaccination.) 

Syphilis is believed to be a microbic disease, but further investigations 



SYPHILIS. 231 

are required in order to determine positively which microbe is the causal 
agent. Klebs obtained by cultivation bacilli which he found in indurated 
chancres. With these bacilli he produced a local affection by inoculation of 
the monkey which resembled, in some respects, that of syphilis and in other 
respects that of tuberculosis. Ziegler and Von Rinecker obtained negative 
results from similar experiments (Ziegler's Path. Anatomy). Lustgarten 
has described a bacillus which occurs in syphilitic lesions, and which he dis- 
tinguishes from that of tuberculosis by colorations which the latter receives 
and this does not, Alvarez and Tavel in 1885, and later Cornil, describe a 
bacillus found in the desquamation of the genitals which closely resembles 
Lustgarten's bacillus of syphilis, but which Cornil states can be distin- 
guished from it by certain differences in the coloration (Cyclop, of Diseases 
of Children, vol. i. 168, Phila., 1889). 

Dr. "W. H. Welch, the distinguished professor of pathology in Johns Hop- 
kins University, has favored me with the following note relating to the micro- 
organism which causes syphilis : 

Baltimore, Aug. 14. 

There has hitherto been no satisfactory demonstration of this organism, although 
there have been many claims to its discovery. The only organism yet demonstrated 
which has any claims to being considered the cause of this disease is, in my opinion, 

the bacillus of Lustgarten There is much to be said in favor of the bacillus 

discovered by Lustgarten, and first described by him in November, 1884, and I 
think this is the only micro-organism hitherto observed in syphilitic lesions which 
possesses much interest. His work from the first attracted attention, as it was done 
under the direction of Prof. Weigert, one of the greatest living experts in this line 
of study. The organism is described by Lustgarten as a bacillus three to seven 
micro-millimetres long, often slightly wavy in shape, and found usually within the 
protoplasm of cells in syphilitic products. It was found by Lustgarten in all 
of the syphilitic products, including gummata, which he examined. Next to 
Lustgarten's, the most important studies of this bacillus have been made prob- 
ably by Doutrelepont of Bonn, in co-operation with Schutz ; by Matterstock of 
Wiirzburg ; by Markase ; and by Fordyce. The significance of Lustgarten's dis- 
covery for a time seemed to be overthrown by the detection by Matterstock and by 
Alvarez and Tavel of a bacillus in smegma, which these observers believed to be 
identical with Lustgarten's syphilitic bacillus ; but, although strikingly similar, 
these two species of organism have now, I believe, been shown to be entirely differ- 
ent species, and the smegma bacillus has nothing to do with the syphilis bacillus. 

Lustgarten's bacillus has not been cultivated, notwithstanding repeated attempts 
to find a medium suitable for its growth. It is certainly often, and probably con- 
stantly, present in syphilitic lesions. Still, several observers have reported negative 
results in searching for it. The reason of this is probably the extraordinary diffi- 
culty in demonstrating this organism. There is nothing in all histological technique 
which requires such an outlay of time and patience as the demonstration of the 
syphilis bacillus, so that so skilled an histologist as Weigert says that he simply 
has not the patience to work at this subject : and this is probably the conclusion 
of others who have tackled it. 

It is clear, however, that the discovery of a peculiar bacillus with remarkable 
staining properties, enclosed within cells in syphilitic products, is something of 
great significance — far greater than finding, as did Aufrect, ordinary cocci in juice 
squeezed out of a flat condyloma, or in mistaking plasma-cells for clumps of cocci. 
as Birch-Hirschfeld is known to have done. When, in addition to this, the lew 
good observers, who, like Lustgarten, have had the patience and skill to make a 
satisfactory study of the question, claim to find this peculiar bacillus so frequently 
in the lesions of syphilis, I think it must be admitted that this bacillus has special 
claims upon our consideration. It must be admitted, however, that a complete 
demonstration that Lustgarten's bacillus is the specific cause of syphilis has not as 
yet been furnished. 

It may interest you to know that within the last year or two some interest has 
attached to the observation first made by Kassowitz and Hochsinger. that strepto- 
cocci are often present in congenital syphilis ; but I do not think that there can be 



232 CONSTITUTIONAL DISEASES. 

any doubt that these streptococci have nothing to do with the specific contagium 
of syphilis (and, indeed, Doutrelepont has found Lustgarten's bacillus in combi- 
nation with streptococci in congenital syphilis), but they are evidence of mixed 
infection. They are probably the ordinary streptococci of suppuration. It is, how- 
ever, of some interest to have this bacteriological evidence of a clinical fact, that 
many cases of congenital syphilis are examples of mixed infection. It is probable 
that some lesions of congenital syphilis which have been regarded as specific, 
particularly those of a suppurative character, are due to the secondary invasion 
of these streptococci, for which the soil has been prepared by the specific organism 
of syphilis. Yours very truly, 

W. H. Welch. 

It is evident, in consequence of the risk of begetting syphilitic children, 
that one who has contracted syphilis should not niarry or sustain conjugal 
relations until four years have elapsed from the time of infection and the 
disease has passed through its first and second stages, and eighteen months 
of treatment have been employed. We have seen that hereditary syphilis 
may be inherited from either parent, although the parent do not exhibit at 
the time any syphilitic symptoms, and that the mother, contracting syphilis 
during gestation even as late as the seventh month, may transmit it to her 
infant. 

Clinical History. — The effects of the syphilitic poison upon the devel- 
opment of the foetus and the development and health of the infant are differ- 
ent in different cases. The foetus, under the influence of the poison, often 
ceases to grow, shrivels, dies, and is expelled long before term ; or it may be 
born alive, but prematurely, and showing clear evidences of the disease as 
soon as it comes into the world ; or, again, it may be born at term, but dead. 
So frequently is syphilis a cause of non-viability that, as Trousseau has 
remarked, this disease should be suspected as the cause whenever a woman 
repeatedly aborts. Abortion from syphilis commonly occurs at or about the 
sixth month of gestation. In those cases in which the foetus dies from syph- 
ilis there is often placental syphilitic disease — to wit, an undue growth of 
cells in the villi, which, compressing the vessels, gives rise to fatty degenera- 
tion and prevents the requisite interchange between the maternal and foetal 
blood (Harring, Frankel). Frankel designated the change " granulation-cell 
hypertrophy of the placental villi." Yirchow in one case found a gummy 
tumor in the maternal portion of the placenta. 

When a foetus destroyed by syphilis is expelled, it frequently presents a 
macerated appearance, the cuticle being detached over large patches of sur- 
face, and in other parts raised in blebs, with a thin, puriform, and offensive 
fluid underneath ; the liver is occasionally indurated, and abscesses with spots 
of inflammation are sometimes observed in the thymus gland ; the amniotic 
fluid is offensive, turbid, and of a greenish or greenish-brown appearance. 

If the foetus in which syphilitic manifestations have begun to occur have 
reached a viable age and be born alive, it is small and imperfectly developed, 
often shrivelled and senile in appearance. The skin looks unhealthy, and it 
may exhibit a distinct rash. Bouchut saw a seven and a half months' infant 
born alive, with an eruption of a copper color upon the legs and arms and 
onychia upon the fingers and toes. The bullae of pemphigus are also not infre- 
quent upon the skin at birth, or they appear within a few days (two or three) 
after birth. The smallest are about the size of a split pea, but many are 
considerably larger ; the largest consist of two or more which have coalesced. 
They contain a thin, greenish, purulent matter, and appear most frequently 
upon the palms of the hands and soles of the feet, but also in severe cases 
upon the face and over the surface of the body. Eecently I was able to 
diagnosticate syphilis in an infant within a day after birth by its small size 
and feebleness and the appearance of large blebs of pemphigus upon its 



SYPHILIS. 233 

hands, feet, fingers, and toes, over which the skin soon broke leaving trouble- 
some and bleeding sores ; coryza commenced about the twelfth day. The 
parents seemed healthy, but I was enabled to trace the syphilitic taint to the 
mother. Non-syphilitic pemphigus, the result of cachexia, sometimes appears 
soon after birth, but its primary and usual seat is around the neck and upon 
the body. I have known it to appear within the first week of life, and end 
fatally by the close of the second week. I have not found it difficult to dis- 
tinguish it from syphilitic pemphigus by the history of the family and its 
absence from the palmar and plantar surfaces of the hands and feet. Con- 
dylomata, mucous patches, and stains of a copper color are the principal 
syphilitic affections, besides pemphigus, which have been observed at birth 
on the bodies of contaminated infants. It is stated that M. Cullerier in ten 
years' attendance at the Hopital de Lorraine met only two cases of syphilitic 
manifestations at birth, and Victor de Meric only two cases in forty-six 
infants, who were affected with congenital syphilis (Bumstead) ; but in the 
practice of others a larger proportion have exhibited symptoms at birth. 
Ordinarily, the period in which congenital syphilis is first revealed by symp- 
toms is between the fifteenth and fortieth days. Rarely the manifestations 
of the disease are delayed several months. M. Diday ascertained the time of 
the commencement of symptoms in 158 cases, as follows : 

Before the completion of one month after birth, in 86 

Before the completion of two months after birth, in 45 

Before the completion of three months after birth, in 15 

At four months 7 

At five months 1 

At six months 1 

At eight months 1 

At one year 1 

At two years 1 

When the symptoms do not occur until several weeks have elapsed, it is 
probable that the poison has been partially eradicated from the affected 
parents by appropriate treatment. 

The nutrition of the infant who has inherited the syphilitic taint, but 
does not exhibit it at birth, is for a time good, but it begins to be impaired 
when the local manifestations of syphilis appear or soon after. The system 
gradually wastes ; the skin loses its fresh and healthy appearance and becomes 
sallow, and after a time more or less wrinkled ; the features become pinched 
and contracted and wear a sad expression. M. Diday says : " Next to this 
look of little old men, so common in new-born children doomed to syphilis, 
the most characteristic sign is the color of the skin." Trousseau thus described 
this discoloration of the surface : " Before the health becomes affected the 
child has already a peculiar appearance ; the skin, especially that of the face, 
loses its transparency ; it becomes dull, even when there is neither puffiness 
nor emaciation ; its rosy color disappears, and is replaced by a sooty tint. 
which resembles that of Asiatics. It is yellow or like coffee mixed with 
milk, or looks as if it had been exposed to smoke ; it has an empyreumatie 
color, similar to that which exists on the fingers of persons who are in the 
habit of smoking cigarettes. It appears as if a layer of coloring had been 
laid on unequally ; it sometimes occupies the whole of the skin, but is more 
marked in certain favorite spots, as the forehead, eyebrows, chin, nose, eye- 
lids — in short, the most prominent parts of the face; the deeper parts, such 
as the internal angle of the orbit, the hollow of the cheek, and that which 
separates the lower lip from the chin, almost always remain free from it. 
Although the face is commonly the part most affected, the rest of the body 



234 CONSTITUTIONAL DISEASES. 

always participates more or less in this tint. The infant becomes pale 
and wan." 

The infant whose system is profoundly affected by syphilis rarely smiles 
and its voice is feeble and plaintive ; its frequent, whimpering cry is quite 
characteristic. 

Coryza is one of the earliest and most constant of the local affections in 
infantile syphilis. It is slight at first, attracting little attention on the part 
of the parents, who are not aware of its significance and usually attribute it 
to a slight cold ; but it gradually increases. It gives rise to a secretion from 
the Schneiderian membrane, at first thin, but which becomes more consistent 
and is attended by the formation of scabs. The thickening of the mucous 
membrane in consequence of the inflammation and the presence of crusts 
narrows the passage through the nostrils, so as to produce snuffling respira- 
tion and sometimes render nursing difficult. In severe cases respiration 
through the nostrils is almost wholly prevented, so that death may occur 
from inanition, unless the breast be milked into the infant's mouth or it be 
fed with a spoon ; but ordinarily, even in grave coryza, it continues to nurse, 
though obliged often to release its hold of the nipple to obtain breath. It is 
when the coryza interferes with drawing the nipple that it first alarms the 
parents. The inflammation at the same time may affect the throat and 
larynx, causing hoarseness of the voice. Ulceration of the Schneiderian mem- 
brane and the adjacent cartilage or bone is rare in infancy or childhood, 
although cases occur which are even attended with more or less flattening 
of the nose. Diday believes that the discharge which accompanies coryza 
is in great part due to mucous patches developed on the Schneiderian mem- 
brane. The upper lip, over which the discharge flows, becomes red, excoriated, 
and more or less incrusted. The coryza in most cases coexists with other 
local syphilitic affections. Occasionally it occurs alone, and is the only evi- 
dence of the presence of the specific taint, except such as is afforded by the 
malnutrition and general appearance of the patient. 

Mucous patches occur in most patients. They are developed either upon 
the mucous surfaces or upon parts of the skin which are thin and exposed 
to friction, and such as are moistened by secretion or transudation from the 
vessels underneath. The most common seat of mucous patches is at the ter- 
mination of mucous canals ; but in infancy, on account of the peculiar deli- 
cacy of the skin, they may occur upon almost any part of the cutaneous 
surface. They are most common, however, around the anus, upon the vulva, 
scrotum, umbilicus, labial commissures, in the axillae, and behind the ears. 

Mucous patches upon the skin present a rounded border and are slightly 
elevated. Their color has been compared to that of skin which has been 
softened by the prolonged application of a poultice. Erosions and cracks 
sometimes occur in the patches, from which a thin liquid exudes. 

Upon mucous surfaces they are less elevated than upon the skin, and are 
prone to ulcerate. These ulcerations, commencing at the centre, extend, and 
soon the mucous patch disappears and its site is occupied by an ulcer. The 
ulcer may be circular, oval, elliptical, crescentic, or irregular. The arches 
of the fauces are a common seat of mucous patches. 

Roseola is an occasional symptom of infantile syphilis. "It is distin- 
guished," says Diday, " by patches of a bright rose color, circumscribed, 
irregularly rounded, of various sizes (most frequently about as large as one 
of the nails) ; appearing by preference on the belly, lower part of the chest, 
neck, and inner surface of the extremities." The spots do not readily and 
fully disappear by pressure. 

Pemphigus, appearing soon after birth, has already been alluded to. Its- 
most frequent seat, whether occurring at birth or as a subsequent manifesta- 



SYPHILIS. 235 

tion, is as we have stated, the palms of the hands, soles of the feet, the fingers, 
and the toes. This eruption commences by a violet tint of the skin, and in 
the course of twenty-four to forty-eight hours a watery fluid collects under- 
neath, which soon becomes turbid. The skin peels off, and sometimes an 
angry sore results, which bleeds readily when rubbed or pressed. In other 
and more favorable cases new skin takes the place of that which is lost. 
Pemphigus at birth is a precursor of death, but when it appears for the 
first time some weeks after birth, it is a less unfavorable prognostic sign. In 
cases of recovery it disappears, with proper treatment, in two or three weeks. 

Acne, Impetigo, and Ecthyma are occasionally observed in children afflicted 
with syphilis. The indurated pustules of acne occur most frequently upon 
the shoulders, back, chest, and buttocks. The pus is sometimes absorbed and 
in other cases discharged, leaving a small cicatrix, which after a time dis- 
appears. Impetigo appears most frequently upon the face, and occasionally 
upon the chest, neck, axillae, and groin. Unlike simple impetigo, the syphi- 
litic impetiginous eruption is surrounded by a copper-colored areola. Ecthyma 
occurs upon the legs and buttocks chiefly. It commences as violet-colored 
spots, which are soon transformed into pustules. Ulcers succeed, which in 
reduced states of the system sometimes enlarge and endanger the safety of 
the child. Of the three pustular eruptions, acne, according to Diday, is the 
least serious, indicating a " less confirmed diathesis." Ecthyma is the most 
serious, on account of the reduced state of the system with which it is usually 
associated. Syphilitic papulae and squamae are rare in infants, but cases have 
been observed. Onychia occasionally occurs, though less frequently than in 
syphilis of the adult. 

In an interesting lecture on hereditary syphilis Dr. Miller remarks that 
polymorphism of its cutaneous eruptions characterizes hereditary syphilis. In 
1000 cases of the inherited disease the local affections referable to syphilis, 
and seated upon or in immediate relation with the cutaneous and mucous 
surfaces, were as follows : x 

Papules 74 per cent, of the cases. 

Khagades of the lips and anus 70 " " " 

Khinitis 58 " " 

Ulcers of hard palate 52 " " 

Erythematous eruptions .45 " " " " 

Lymphadenitis chronica 20 " " " 

Ulcers of tongue (glossitis ulcerosa) 27 " " " 

Bullous eruptions (pemphigus) 25 " " " 

Onychia and paronychia 23 " " " 

Laryngitis 17 " " " 

Pseudo-paralvsis of extremities 7 " " " 

Ulcers 4 " " 

Ulcerative gingivitis 4 " " " 

Visceral Lesions. — The visceral lesions which result from the syphilis of 
infancy and childhood are suppuration in the thymus gland; gummy tumors 
in certain organs, most frequently the lungs and liver ; increase of the con- 
nective tissue of the liver, known as syphilitic cirrhosis; partial perihepatitis. 
with depressions resembling cicatrices on the surface of the liver; periostitis. 
with thicking of the bone ; and exostosis. 

Suppurative inflammation in the thymus gland is not common or has not 
been frequently observed. When it is present the gland sometimes presents 
its normal appearance externally, and the abscess is only discovered by incis- 
ions. Gummy tumors are white and spheroidal ; some arc as small or smaller 
than a pin's head, while others are as large as a pea or even a hazel-nut. T 

1 Pacific Med. Surg. Jouni., 1888. 



236 CONSTITUTIONAL DISEASES. 

have seen a considerable number of them not as large as a pin's head in the 
liver of an infant. Gummy tumors, according to Lebert, consist " of loose 
fibrous tissue made up of pale, elastic fibres, enclosing in their large inter- 
spaces a homogeneous granular substance, the elements of which are less adhe- 
rent to each other than in deposits of true tubercle." Lebert also, with other 
microscopists, discovered round granular cells in these tumors. According to 
Robin, gummy tumors " are made up of rounded nuclei belonging to fibro- 
plastic cells, or cytoblastions ; of a finely granular, semi-transparent, and amor- 
phous substance ; and, finally, of isolated fibres of cellular tissue, a small 
number of elastic fibres, and a few capillary blood-vessels." 

Constitutional syphilis is one of the principal causes of waxy degenera- 
tion, and the spleen and liver of infants may be enlarged from this cause. 
Dr. Samuel Gee has expressed the opinion that in half the cases of hereditary 
syphilis the spleen is enlarged {London Lancet, April 13, 1867). 

Infiltration of the liver by fibrous substance was first noticed by Gubler. 
It is not common in the infant. A specimen, showing this lesion, was pre- 
sented to the London Pathological Society in' 1866 by Dr. Samuel Wilks. 
The following remarks by Dr. Wilks convey a good idea of the appearance 
and state of the liver in syphilitic cirrhosis : " Having dissected the bodies 
of several infants who have died of congenital syphilis, I have found fatty 
livers and an inflammation of the capsule, but in only two have I discovered 
adventitious products of a fibrous character. The present example, however, 
corresponds in every particular with the disease described by Gubler. It 
must be distinguished (at least as far as the naked-eye appearance reaches) 
from syphilitic disease of adults, of which many specimens have been before 
the society. In these the organ is cicatrized on the surface and contains dis- 
tinct nodules of fibrous tissue ; while in the disease of children, as in the 
present specimen, the whole organ is infiltrated by a new material, and it 
consequently becomes, as described by Gubler, hypertrophied, globular, and 
hard, resistant to pressure, and even when torn by the fingers its surface 
receives no indentation from them ; it is also elastic, and when cut creaks 
slightly under the scalpel. This was the form of disease in the present 
specimen. It came from a syphilitic child a month old, in whom the liver 
could be felt enlarged during life, and when removed weighed a pound and a 
half. It was smooth on the surface, and so hard that it resembled rather a 
fibrous tumor than a liver. It is seen that the liver in the syphilitic child is 
liable to three distinct pathological processes — namely, gummy tumors, cir- 
rhosis or fibroid degeneration, and waxy degeneration." 

Syphilitic perihepatitis and periostitis are more rare in infancy and child- 
hood than in adult life, but they occasionally occur. The late Sir James Y. 
Simpson considered peritonitis in the foetus one of the results of syphilis, and 
a cause of its death. 

Osseous Lesions. — Within the last few years important discoveries have 
been made in regard to the effect of syphilis upon the nutrition of the bones 
in children. In 1870, Dr. Wegner of Berlin published his observations of the 
state of the skeleton in twelve syphilitic children who were either stillborn 
or who died within a few days or weeks after birth. He found clear proof 
that the syphilitic dyscrasia frequently disturbs the nutrition and produces 
anatomical changes in the skeleton of the foetus. The following are the 
lesions clearly referable to syphilis which he observed : Periostitis of long 
bones, including the ribs ; softening', separation, and sometimes crepitation at 
the point of union of diaphysis and epiphysis ; chalky concretions and infil- 
trations along the line of ossification ; fatty degeneration of marrow ; irreg- 
ular formation and distribution of spongy substance in the epiphysis. These 
lesions were not all observed in each case, but they occurred with such fre- 



SYPHILIS. 237 

quency that tliere could be no doubt that they were due to the syphilitic taint 
of system. Confirmatory observations also in twelve cases have since been 
made by Waldeyer and Kobner. 1 

Again, there is a syphilitic lesion of the bone in children which is not 
usually present or has not usually been observed at birth, but is developed 
in the first weeks or months of infancy. The lesion alluded to is a circum- 
scribed enlargement of one or more bones. This has been most frequently 
observed upon the long bones, including the clavicle and ribs, but in certain 
children it occurs upon other bones in addition. In some cases it is one of 
the first manifestations of hereditary syphilis, occurring even sooner than the 
coryza, while in others several months elapse before it appears. In one case 
reported by Dr. Bulkley 2 of this city it was first seen only a few days after 
birth, being perhaps congenital ; while in another case, in which the enlarge- 
ment was upon certain phalanges, and which is represented in the accompany- 




ing figure, it appeared at the age of twelve months. When it occurs upon a 
phalangeal bone it is designated dactylitis syphilitica. 

The enlargement, if upon a long bone, ordinarily begins at or near the 
point of union of the diaphysis with the epiphysis. It is located upon the 
extremity of the shaft, which it encircles, and it extends over a part or nearly 
the whole of the epiphysis. It has an elevation of perhaps one-half or three- 
quarters of an inch in typical cases : its surface is smooth or slightly undu- 
lating, and the skin over it, though distended, has its normal appearance and 
is easily movable, unless ulcerations have occurred. 

These enlargements, which result from the specific inflammation occurring 
in the periosteum and the bone, may resolve under proper treatment : but if 
neglected and the antihygienic conditions are bad, degenerative changes may 
occur, ending in ulceration and destruction of the diseased part to a greater 
or less extent. 

1 See paper by K. W. Taylor, M. D., New York Journal of Obstetrics, etc, July. 
1874. 

2 "Bare Cases of Congenital Syphilis," New York Med. Journal, May, IS, 4. 




238 CONSTITUTIONAL DISEASES. 

Though these bone-enlargements, whenever observed, should excite suspi- 
cions of syphilis as the cause, enlargements which present the same general 
appearance do occur from other causes. Such a case was observed by me in 
the children's class in the Out-door Department of Belle vue, and Dr. Bulkley 
details another case in his paper. In the case observed by me the inflamma- 
tion and enlargement seemed to be strumous. Baumler says : " Dactylitis 
syphilitica does not always originate in the bone ; similar appearances may 
be produced through gummous formation in the sheaths of the tendons and 
in the fibrous structure of the finger;" and again, " Its outward appearance 
may be produced also by tuberculosis, enchondroma, or sarcoma of the bone- 
marrow " (art. " Syphilis,"' Ziemssens Encycl.). 

Mr. J. Hutchinson of London has called attention to the fact that hered- 
itary syphilis, having perhaps been manifested by the usual symptoms during 

infancy and then becoming latent, may give 
FlG - 41 - rise to new symptoms after the fourth year. 

The most noticeable of these symptoms is a 
dwarfing of the permanent incisor teeth, which 
are rounded and peg-like and their enamel 
notched at the free ends of the teeth. On 
account of the small size and shape of the 
teeth there are interspaces between them. 
This abnormal development is most marked 
in the central incisors of the upper jaw, and in certain cases it is limited to 
them, and it never appears in the other incisors unless it does also in them. 
Another symptom, which only appears in hereditary syphilis, is an interstitial 
keratitis occurring on both sides and attended by the deposition of fibrin in 
the substance of the cornea. In a few weeks the inflammation declines, but 
a slight opacity of the cornea remains. The cerebral nerves may become 
affected, usually a single pair — if the auditory, deafness resulting ; if the 
optic, dimness of sight. Occasionally there are other manifestations of 
syphilis in this period, as enlargement of spleen and liver and nodes upon 
the long bones. 

Prognosis. — This depends in great part on the general condition of the 
patient. If there be much emaciation and the symptoms indicate a deeply- 
seated cachexia, a considerable proportion of the patients perish. On the 
other hand, if the general health be not greatly impaired, although the local 
affections are pretty severe, the prognosis with correct treatment is good. 
The younger the infant when the symptoms of syphilis appear, the more 
unfavorable, as a rule, is the prognosis. 

Treatment. — Parents who beget syphilitic children ought, from a due 
regard for their offspring to make use of antisyphilitic remedies, although 
they present in their persons no evidences of syphilitic taint. A good pre- 
scription for the parents is one-sixtieth of a grain of corrosive sublimate in 
the compound tincture of bark, given twice or three times daily for several 
months. If the father have had syphilis, both parents should be subjected to 
this treatment, and it may be continued, at least on the part of the mother, 
during the first months of her gestation. So small a dose of the mercurial 
does not, in my opinion, materially increase the liability to miscarry. There 
is much more danger of miscarrying from allowing the syphilitic taint to 
remain uncontrolled. Some prefer the use of mercurial ointment in the 
treatment of pregnant women having syphilis, in the belief that it is less 
likely to produce abortion. It is used for this purpose in the proportion 
of one drachm to the ounce. It is equally effectual in the eradication of the 
syphilitic taint with the small dose of corrosive sublimate recommended above 
for internal administration ; but it is impossible to determine the quantity of 



SYPHILIS. 239 

mercury which enters the circulation when inunction is employed and saliva- 
tion is more likely to occur. The following is, however, probably the best 
prescription for the treatment of parents infected by the syphilitic virus. It 
should be given for several months : 



Or 



R. Hydrarg. biniodidi, 


Rt. j ; 


Liq. potassii arsenit., 


3J; 


Tine, belladonnse, 


3y ; 


Potassii iodidi, 


.Iss; 
ad 5iv.— M. 


Aquae, q. s. 


Dose : One teaspoonful three times daily after the meals. 


R. Yini, 


s v J; 


Pepsini pari in lamellis, 


3ij; 


Potassii iodidi, 


3y ; 


Liq. potassii arsenit., 


3y; 


Hydrarg. biniodidi, 


g r - j ; 


Qui. et ferri citratis, 


3*j ; 


Syr. simplic., 


gij; 


01. anisi, 


gtt. iij. — Misce. 


Dose : One dessertspoonful three times daily. 





The nutrition of the infant that has unfortunately inherited the syphilitic 
taint requires special attention. Besides exhibiting the characteristic symp- 
toms of the disease, it usually suffers from innutrition, and sometimes passes 
into a state of decided marasmus. The mother who has given birth to a 
syphilitic infant should, if possible, wet-nurse it. Even if she never has 
exhibited any symptoms of the disease in her own person, she cannot contract 
syphilis from her infant. Colles wrote as follows in 1837 : " One fact well 
deserving our attention is this : that a child born of a mother who is with- 
out obvious venereal symptoms, and which, without being exposed to any 
infection subsequent to its birth, shows this disease when a few weeks old, — 
this child will infect the most healthy nurse, whether she suckle it or merely 
handle and dress it ; and yet this child is never known to infect its own 
mother, even though she suckle it while it has venereal ulcers of the lips and 
tongue." This remarkable law relating to the immunity of mothers has been 
fully accepted by all subsequent syphilographers. On the other hand, a wet- 
nurse employed to suckle a syphilitic infant is very liable to contract the dis- 
ease, through her nipples, from the infected lips of the infant. If a wet-nurse 
be employed for such an infant, she should be aware of the risk she incurs, 
and should protect herself by the use of an artificial nipple. At the same 
time, the infant should be placed fully under antisyphilitic treatment. Arti- 
ficial feeding, though usually disastrous, is preferable to the propagation of 
the disease to a healthy wet-nurse. 

Syphilis in the infant requires mercurial treatment as in the adult. Mer- 
cury may be employed internally or by inunction. Some prefer inunction in 
the treatment of ordinary cases in the manner recommended by Sir Benjamin 
Brodie. " I have spread," says he, " mercurial ointment, made in the pro- 
portion of a drachm to an ounce, over a flannel roller, and bound it round 
the child once a day. The child kicks about, and, the cuticle being thin, the 
mercury is absorbed. It does not either gripe or purge, nor does it make the 
gums sore, but it cures the disease. I have adopted this practice in a great 
many cases with the most signal success." The oleate of mercury, 10 per 
cent., is a better preparation for inunction. Five drops may be rubbed in 
three times daily. Trousseau, on the other hand, discountenances the use 
of inunction, since mercurial ointment applied to the skin produces irritation 



240 CONSTITUTIONAL DISEASES. 

and increases the suffering and restlessness of the child. He prefers the fol- 
lowing solution, which is known as Van Swietens, for internal treatment : 

R. Hydrarg. bichlorid., 1 part ; 

Aquae, 950 parts ; 

Spts. rectific, 100 parts. — Misce. 

Dose : One or at most two grammes (15.434 to 30.868 grains), in milk, daily. 

In order to avoid the risk of establishing a diarrhoea, and to leave the 
stomach free for the employment of other medicines, as cod-liver oil and the 
iodide of iron, I prefer and commonly prescribe for infants inunction with 
the mercurial ointment diluted with eight times its quantity of lard, cold 
cream, or vaseline. It should not be applied as a plaster, but a quantity of 
the size of a large chestnut should be rubbed three times daily upon the 
neck or breast of an infant of three or four months. For children over the 
age of eight or ten months, Van Swieten's or one of the following formulae 
may be employed : 

R. Hydrarg. cum creta, gr. iij-vj ; 

Sach. alb., 9j. — Misce. 

Divid. in chart. No. xii. One powder three times daily. 

R. Hydrarg. chlor. corros., gr. ss-j ; 

Syr. sarsse. comp., 31J ; 

Aquae, o vn J- — Misce. 
Dose : One teaspoonful three times daily. 

R. Hyd. chlor. corros., gr. ss ; 

Potas. iodid., gj ; 

Ferri et ammon. citrat., gj ; 

Syr. simplic, ^vj. — Misce. 

Dose : One teaspoonful three times daily for a child of three to five years. 

R. Hyd. chlor. corros., gr. j ; 

Potas. iodid., gij ; 

Syrup, simplic, 

Aquae, da. ^ij. — Misce. 

Dose : Six drops three times daily for a child of three months. 

Prof. A. Jacobi recommends, in the treatment of syphilis of the newly- 
born, one-twentieth of a grain of calomel, to be given three times daily. An 
important advantage of its use is the rapidity and certainty of its action. 

Mercury, in whatever way employed, should not be discontinued entirely 
till several weeks after the syphilitic symptoms have disappeared ; it is proper 
to continue it for a time, in diminished quantity and fewer doses, after the 
health seems fully restored. 

When the mercurial treatment is omitted tonics are often required. The 
preparations of cinchona are useful in certain cases, as are also those of iron. 
If the patient remain feeble and pallid, presenting evidences of struma, cod- 
liver oil and syrup of the iodide of iron will be found beneficial, continued for 
some weeks or months after the mercury is discontinued. Attention should 
always be given to cleanliness and the hygienic management of the patient. 
In some instances direct treatment of the local affection is serviceable. To 
aid in the cure of syphilitic coryza the following ointment should be applied 
within the nostrils by a nasal sponge three times daily : 

R. Ung. hydrarg. nitratis, £ij ; 

Ung. zinci oxidi, Jij. — Misce. 



SYPHILIS. 241 

Recently I have been in the habit of employing Squibb's oleate of mer- 
cury, 2 per cent., for syphilitic coryza of infants, and the effect has been 
satisfactory. It may also be employed by cutaneous inunction in the treat- 
ment of the general disease. 

Condylomata or mucous patches seated upon the cutaneous surface should 
be dusted with calomel. At my clinique in April, 1871, a child two years 
and ten months old was presented, with a large condylomatous outgrowth 
near the anus. The history of the child showed that in all probability the 
disease had been contracted within a year from syphilitic children in one of 
the public institutions. Within three weeks this affection disappeared by 
dusting upon it calomel once daily, with appropriate internal treatment. 

The infant should be kept clean by bathing it in tepid water twice daily, 
and excoriations upon its lips or mucous patches should be bathed before the 
nursing with some mild disinfectant solution, as boric acid. The best pos- 
sible hygienic conditions should be provided for the infant, since cachexia is 
commonly present. It should be taken outdoors frequently in suitable weather, 
and its removal from the city to the country, especially in hot weather, may 
be advisable. The cachexia which remains after the disappearance of the 
syphilitic manifestations requires the use of tonics, as cod-liver oil and syrup 
of the iodide of iron. 

Syphilitic symptoms may reappear during childhood. The exanthemata 
rarely appear at this age when the proper treatment has been employed in 
infancy, but condylomata and gummy tumors may, and they require a return 
to the mercurial treatment. If the bones are affected the iodide of potassium 
is the proper remedy. It causes the disappearance of the periosteal pains 
and swelling, and manifest improvement in the symptoms generally. 
16 



SECTION" II. 
ERUPTIVE FEVERS. 



CHAPTER I. 

MEASLES. 



The disease known in the vernacular as measles has also the names 
rubeola and morbilli. It is a common exanthematic affection occurring at 
any age, but most frequently in childhood. It affects once the majority 
of mankind. Writers recognize three stages of measles : first, that of inva- 
sion, which ends with the appearance of the eruption ; secondly, the eruptive 
stage ; and, thirdly, the stage of decline or desquamation. 

Etiology. — Micrococci have been found in the blood of rubeolar patients 
by Coze and Feltz. Keating also discovered them during an epidemic of malig- 
nant measles (Phila. Med. Times, Aug. 12, 1882), and Ransome, Braidwood, 
and Vacher found them in the breath of patients as well as in their tissues 
(Brit, lied. Journ., Jan. 21, 1882). It seems probable that they are the specific 
principle ; if so, they remain dormant in the system about twelve days, which 
is the incubative period. Additional observations are required in order to 
determine positively whether this micrococcus be the causal agent in measles, 
or whether it may not be some other microbe. 

Symptoms. — This disease commences with such symptoms as usually 
occur in mild but pretty general inflammation of the air-passages — to wit, 
cough, fever, anorexia, and thirst. The eyes present a suffused, moderately 
injected, and brilliant appearance, and the buccal and faucial surfaces are 
injected. The Schneiderian membrane and that lining the larynx, trachea, 
and bronchial tubes participate in the increased vascularity. The cough at 
first is dry, and sometimes distinctly croupy. Catarrhal or false croup, indeed, 
is not infrequent in the initial period of measles. The cough is attended with 
slight acceleration of respiration and by little or no pain in the respiratory 
movements. If auscultation be practised at this early stage, we observe the 
vesicular murmur, somewhat harsh in character, and sometimes sonorous and 
sibilant rales. A little later rales of a moist character appear. 

The patient, if old enough, commonly complains of headache and of dull 
pain in the epigastric region or the centre of the sternum, due to the bron- 
chitis. With these local symptoms febrile reaction occurs. The temperature 
rises to about 102° or 103°, as indicated by the thermometer in the axilla. 
The pulse numbers from 110 to 130 per minute. The febrile movement is 
greater than in primary tracheo-bronchitis, except when the bronchitis extends 
to the bronchioles, but it is less than in most cases of scarlet fever. 

The fever in the premonitory stage of measles after the first day is not 
uniform. It is attended by remissions and exacerbations, the former occur- 

242 



MEASLES. 243 

ring in the first part of the day, the latter in the evening. Sometimes two 
exacerbations occur in the day. The face is flushed and somewhat swollen, 
especially during the times of increase in the fever, and the child is drowsy 
or restless. Vomiting, so common a symptom in the commencement of scarlet 
fever, occasionally occurs in measles. While in scarlet fever this takes place 
in the first twenty-four hours, in measles it takes place with about equal fre- 
quency at any period previously to the eruption. It was present during the 
first stage, sometimes almost as late as the eruptive period, in 13. and was 
absent in 23 cases in which I preserved records in reference to this symptom. 

The duration of the first stage varies in different cases. It is usually from 
two to five days, with an average of about four. Occasionally it is more pro- 
tracted on account of some disturbance in the economy, either from exposure 
to cold or other cause, which prevents the necessary afflux of blood toward 
the surface and retards the eruption. In 18 cases in my practice in which 
the duration of the cough previously to the appearance of the rash was accu- 
rately ascertained, the time varied from one to five days, with an average of 
three and one-third; in 10 other cases it had continued, the parents stated, 
about a week; and in 5, from one to two weeks previously to the eruption. 

The eruption commences, when the disease pursues its normal course, upon 
the forehead and neck, then the face, and gradually extends downward, occu- 
pying from twenty-four to thirty-six hours in passing over the trunk and 
limbs. It appears first as indistinct red points, not more than a line in diam- 
eter, which increase in size and become more distinct. Their borders are 
uneven or irregular or they are finely notched ; their general shape is, how- 
ever, circular, except as two or more unite, when they may assume any form. 
The crescentic form which writers describe is due to the union of two points 
of eruption. The largest of these points, when there is no coalescence, do 
not exceed a quarter of an inch in diameter, and many are much smaller. 
Frequently in plethoric children, if there be much fever, there is continuous 
redness over several inches of surface. The eruption is then confluent. This 
form is often observed upon the parts of the surface where the capillary cir- 
culation is most active when it is discrete elsewhere. In some of these cases 
diagnosis of measles from scarlet fever is attended with difficulty. 

The rubeolous eruption is slightly elevated, the elevation not being appre- 
ciable to the sight, but it can be ascertained by passing the finger over the 
skin, when roughness is felt at the point of eruption. Sometimes the eleva- 
tion, especially in the commencement of the efflorescence, is not appreciable, 
even to the touch. The eruption is broad and flat, never acuminate, never 
changing its form to the vesicular or pustular. It disappears by pressure, 
and immediately reappears when the pressure is removed. It has been com- 
pared in appearance to flea-bites. Small, pointed, papular, vesicular, or pustu- 
lar eruptions are sometimes seen in connection with those of measles, but they 
are accidental, occurring in other states of the system as well as in measles, 
if there be the same augmented temperature. 

In the commencement of the eruptive period the severity of the consti- 
tutional and local symptoms increases. The pulse and temperature corre- 
spond with the character which they presented during the exacerbations of 
the first stage. The features are slightly swollen; the eyes still watery and 
sensitive to light ; the conjunctiva, ocular and palpebral, and the mucous 
membranes of the cavity of the mouth and of the air-passages, continue 
injected. The tongue is covered with a moist thin fur, and its papillae are 
prominent, though less so than in scarlet fever. The cough continues fre- 
quent, and is seldom attended with much expectoration in uncomplicated 
cases; often there is no expectoration whatever. The appetite is lost, but 
drinks are readily taken on account of the thirst. Diarrhoea sometimes 



244 CONSTITUTIONAL DISEASES. 

occurs on the first day of the eruption, but it lasts only a few hours, and, 
if the disease pursue its usual course, abates of itself. With the exception 
of this the bowels are regular or a little constipated during the. eruptive 
period. 

On the second day of the eruption, or sixth of the fever, the symptoms 
begin to abate. The pulse is less accelerated and the temperature diminishes ; 
the cough is less frequent and is easier, and the flushed and swollen appear- 
ance of the face declines. By the close of the third or on the fourth day 
the rash has disappeared in the order in which it extended over the body. 
There only remain faint maculae, which in the course of a day or two fade 
completely. 

With the disappearance of the rash the fever nearly or quite ceases, but 
a slight and painless cough continues for several days. 

Occasionally the eruption presents a livid appearance ; this is the rubeola 
nigra of writers. From cases which I have observed it is my opinion that 
this should not be considered a distinct species in the vast majority of 
patients, but that the dark color is due to internal inflammation, usually 
capillary bronchitis or pneumonia, which prevents full decarbonization of the 
blood. Rarely, rubeola nigra is due to the vitiated state of the blood or the 
malignant nature of the disease. The course of the eruption in this form 
of measles is somewhat different ; it continues longer, fades more slowly, and 
does not disappear so readily on pressure. Traces of it are observed a week 
or more after its first appearance ; it is likely to be fatal. Measles may pre- 
sent this form from the beginning, or, commencing as vulgaris, it may pass 
into rubeola nigra, 

Measles may be irregular in form, but aberrations are less frequent than 
in scarlet fever. Writers describe measles without catarrh, and, on the other 
hand, with catarrh, but without the rash. But positive diagnosis in such 
cases must be difficult. It is probable that simple catarrh and roseola have 
sometimes been mistaken for the two forms of irregularity mentioned ; but 
when a child in a family of children affected with measles presents all the 
symptoms of that disease except the catarrh or except the eruption, the 
diagnosis of irregular measles would, as a rule, be correct. 

Occasionally the stage of invasion is very short or even absent. In one 
case the parents informed me that the catarrhal symptoms began on the day 
when the eruption appeared. Convulsions sometimes occur at the commence- 
ment of measles, as well as during its progress. A single convulsive attack 
at the commencement is usually not dangerous ; when repeated it is more 
serious; it is also more serious when it occurs in the course of measles. 
In certain patients the eruption appears in an irregular and partial manner, 
occurring perhaps at a late period, and indistinctly, upon the trunk alone or 
upon the trunk and partially upon the legs. In many cases of deferred or 
partial eruption there is internal congestion or inflammation of some part, 
which causes withdrawal of blood from the surface, and thus prevents the 
normal development of the rash. 

When the eruption disappears the third stage commences, that of de- 
squamation. It is characterized by a scanty furfuraceous exfoliation of the 
epidermis. The desquamation is seldom as great as in scarlet fever, and it 
occurs most where the eruption has been thickest and the epidermis most 
inflamed. Exfoliation occurs between the fourth and seventh days after 
the commencement of the eruption, the eighth and the eleventh of the 
disease. Frequently it does not take place, or is so slight as not to be 
observed. 

With the disappearance of the rash the symptoms rapidly abate. The 
pulse becomes more natural, the temperature is reduced, the digestive organs 



MEASLES. 245 

return to their normal state-, and convalescence is established. The cough 
continues several days after the other symptoms abate, but it is less and less 
frequent, and is not painful. 

Complications.— The complications of this disease are important. Much 
of the success of the physician in the management of measles depends upon 
a correct diagnosis and understanding of them. The most frequent of these 
complications are bronchitis and broncho-pneumonia. Slight bronchitis is 
uniformly present in measles, but if it increase so as to cause embarrassment 
of respiration and become a source of danger, it is properly a complication. 
This complication, as well as pneumonia, may occur at any period of measles, 
but it commences most frequently in the first stage. Occurring in the first 
stage, it may prevent the regular appearance of the rash ; if in the second 
stage, it often causes retrocession of it. 

When bronchitis becomes really serious it usually has invaded the minute 
bronchial tubes. This disease, designated capillary bronchitis or suffocative 
catarrh. I have elsewhere described. The clinical history of fatal bronchitis 
as a complication of measles is as follows : The respiration, at first not notably 
altered, becomes by degrees accelerated and the patient more and more fret- 
ful. The pulse, instead of becoming less accelerated, as after the first days 
of simple measles, is daily more rapid and the respiration more frequent and 
labored. The dyspnoea gradually increases, the inframammary region is 
depressed during each inspiration, and the subcrepitant rale is heard on both 
sides of the chest. There is probably collapse or inflammation of some of the 
lobules. Finally, the prolabia and fingers become livid, and death occurs from 
apnoea. Capillary bronchitis, occurring as a complication and continuing as 
a sequel of measles, usually becomes a broncho-pneumonia. A large propor- 
tion of those affected under the age of three years die. The anatomical cha- 
racters of fatal bronchitis occurring in connection with measles we have had 
frequent opportunities to inspect in the Foundling Asylum and Infant Asylum. 
In some cases there have been evidences of continuous inflammation from the 
epiglottis downward, ending in lobular or broncho-pneumonia. Broncho- 
pneumonia as a complication does not differ materially from the idiopathic 
inflammation, except that it is more protracted and fatal. 

The next most frequent serious complication of measles is entero-colitis. 
This may commence at any period during the course of the disease. If the 
colon be more especially the seat of inflammation, the evacuations contain 
mucus and blood, unless in young children, in whom the stools, even in 
severe colitis, commonly have a green color. The anatomical character of 
this complication varies in different cases, like the idiopathic form of inflam- 
mation. Sometimes there is simple arborescence of the intestinal mucous 
membrane, with tumefaction of its follicles ; in other cases, in addition to 
increased vascularity, the mucous coat is softened and thickened ; and in 
others still, especially if the inflammatory action has been protracted, ulcer- 
ation occurs, for the most part in the site of the solitary glands. Excep- 
tionally, in fatal cases of measles attended with diarrhoea, no vascularity is 
observed after death, although the intestines may be thickened and softened. 
In such cases the diarrhoea was probably inflammatory, the injection of the 
vessels having disappeared after death. 

Severe and obstinate diarrhoeal affections occurring with measles usually 
commence as the primary disease is about declining. They then become 
sequelae, ending fatally in many instances, especially in the summer months, 
several days or perhaps weeks after the disappearance of the eruption, 
Diarrhoeal attacks occurring in or previously to the eruptive stage arc. as 
a rule, mild and easily relieved. 

In some grave cases measles have a tendency from the first to affect the 



246 CONSTITUTIONAL DISEASES. 

internal organs more than the surface. Bronchitis, pneumonia, and entero- 
colitis may coexist with indistinctness of the eruption on the skin. Such 
complications render a fatal result highly probable. 

Eclampsia is also an occasional very dangerous complication. It some- 
times occurs very suddenly and unexpectedly. A child of five years, in my 
practice, apparently progressing favorably with measles, was allowed to sit at 
dinner with the family ; suddenly and without premonition eclampsia occurred, 
the rash receded, and notwithstanding vigorous treatment death resulted in 
a few hours. Eapidly-developed cerebral congestion seemed to be present. 
To prevent such a complication the patient should remain quiet in bed dur- 
ing the eruptive stage. 

Another very fatal complication and sequel is pseudo-membranous laryn- 
gitis, commencing when rubeola is beginning to decline ; but it is less frequent 
than pneumonia or entero-colitis. In catarrhal or false croup — which, as has 
been previously stated, is not infrequent at the commencement of measles — 
the cough has a loud, ringing character. In membranous laryngitis, on the 
other hand, it is hoarse or harsh and less distinct, on account of the presence 
of the pseudo-membrane in the larynx. This form of laryngitis, always a 
grave disease, is more serious when it occurs as a complication of measles than 
when it is idiopathic, not only because the blood is vitiated and the system 
reduced by the primary affection, but because the inflammation of the mucous 
surface is in general more extensive, as is also the pseudo-membrane. This 
membrane in the croup of measles often extends so far down the air-passages 
that neither intubation nor tracheotomy can produce any decided ameliora- 
tion of symptoms. This complication, though always grave, is not, however, 
necessarily fatal. I have known cases recover by inhalation of solvent sprays 
when for days there had been dyspnoea and other evidences of a pretty firm 
pseudo-membrane. True croup causes continuation of the fever, which had 
perhaps begun to abate. 

Diphtheria, when epidemic, also frequently complicates measles. Much 
of the mortality from measles in this city since the year 1858 was due to 
this cause. In cases observed by myself, diphtheria usually began while the 
fauces were still inflamed, and sometimes before the eruption had begun to 
fade. The pseudo-membranous laryngitis or true croup mentioned above is, 
in most instances, in localities where diphtheria prevails, a local manifestation 
of this disease. 

These are the most common complications of measles. There are others 
of less frequent occurrence, among which may be mentioned stomatitis, pha- 
ryngitis, and otitis sufficiently severe to be considered complications. Rarely, 
also, purpura, attended by hemorrhages from the different mucous surfaces, 
occurs in connection with measles. This complication is, however, more fre- 
quent in certain other constitutional diseases, as scarlet fever, and especially 
variola. 

It is seen that the inflammations which occur in the course of measles 
are chiefly of the mucous surfaces. In scarlet fever, on the other hand, the 
inflammations are more frequently of serous surfaces. 

There are other affections originating in measles which are rather sequelae 
than complications. Gangrene of the mouth is one which, as stated in another 
part of this book, occurs more frequently after measles than any other disease. 
After a severe epidemic of measles in the New York Foundling Asylum in 
1874 three cases of gangrenous vulvitis occurred in those who had been 
affected. Ophthalmia commencing in measles often persists for weeks or 
months. It may give rise to granulation of the lids, and cases have been 
reported of violent inflammation of a purulent character producing ulcera- 
tion of the cornea and destroying vision. The ophthalmia is sometimes very 



MEASLES. 247 

intractable. Inflammation of the Schneiderian membrane, commonly present 
during measles, often continues as a sequel, extending back as far as the 
Eustachian tube, where it may cause swelling, with impairment of hearing, 
and forward to the lip, where it may produce chronic eczema. Prof. Moos 
has described the lesions which occur in the labyrinth in measles when the 
ear is affected. Cells and coagulated lymph fill the semicircular canals and the 
cochlea, and collect in the lymphatics. The blood-vessels in the Haversian 
canals and in the spiral ligament are nearly destroyed. The nerves become 
gelatinous and atrophied ; the muscular fibres undergo waxy degeneration. 
Notwithstanding such lesions, permanent deafness is rare and reparation 
seems possible (Congress at Wiesbaden, Sept. 22, 1887). 

Anatomical Characters. — I have made or witnessed, mainly in insti- 
tutions, a considerable number of post-mortem examinations of those who 
have died in or after an attack of measles. In all there were lesions due to 
complications. Indeed, death directly from measles is so rare that few have 
had an opportunity of studying the anatomical characters apart from the 
complications. In those who have died without any obvious coexisting dis- 
ease — and these cases chiefly occur in the malignant form — there has been 
congestion of the internal organs, especially marked in the lungs, and some- 
times the tissues appeared softened. The blood also in the malignant form 
has a darker hue than natural, and ecchymotic patches have been observed 
upon the mucous surfaces and elsewhere, corresponding in character with the 
petechiae under the skin which sometimes occur in this form of measles. In 
cases resulting fatally from bronchitis or pneumonia the bronchial glands are 
commonly tumefied in the same manner as the mesenteric glands are enlarged 
in enteritis and the glands of the mesocolon in dysentery. 

Nature. — Rubeola, like the other exanthematic fevers, is due to a mate- 
ries morbi, probably micrococci, as has been stated above. It is highly con- 
tagious through the air. It has been inoculated by the serum from vesicles 
which sometimes occur in connection with the rubeolous eruption, and also 
by the blood from a patient. Inoculation does not appear to moderate the 
disease, and as measles, when contracted in the ordinary way, is not in itself 
dangerous, but dangerous only from complications, inoculation is not per- 
formed except as a matter of scientific interest. The usual mode of propa- 
gation is through the air. Measles is communicated by the breath and prob- 
ably by exhalations from the surface. Under whatever circumstances it 
occurs, the specific principle has been communicated from some infected 
person. We frequently meet cases, as in a sparsely-settled district that has 
come to my knowledge, in which exposure cannot be traced. Yet the im- 
munity of certain islands for centuries till infected through commerce renders 
the doctrine of an origin de novo improbable. 

Twelve to fourteen days elapse from the time of infection to the com- 
mencement of the eruption. In cases observed in the children's department 
of Charity Hospital the incubative period was ascertained to be about twelve 
days. In those who have been inoculated the incubative period is said to 
have been about one week. Rubeola prevails epidemically, like the whole 
class of infectious diseases, and in different epidemics the type may vary as 
well as the character of the complications. 

Diagnosis. — The diagnosis of measles previously to the eruption is often 
difficult. The catarrhal symptoms then predominate, and these are such as 
may occur independently of any constitutional or blood disease. The first 
stage, therefore, is not infrequently mistaken for corvza or mild bronchitis. 
The points of differential diagnosis are the suffused appearance of the eyes. 
the greater degree of fever on the first day than would be likely to arise from 
so moderate an amount of local disease, and morning remission and evening 



248 CONSTITUTIONAL DISEASES. 

exacerbation of the fever. Measles in the first stage has been mistaken for 
remittent fever. The catarrhal symptoms should prevent such an error. 

Sometimes roseola closely resembles measles in appearance, but the rash 
of roseola appears within a few hours after the commencement of febrile 
symptoms, and almost simultaneously over the whole body, and without 
those local symptoms referable to the mucous surfaces which characterize 
measles. 

Variola on the first clay of the eruption has sometimes been diagnosticated 
measles. I recollect once being called to an infant with fatal confluent small- 
pox who was said to have measles. A physician a few days previously, observ- 
ing the red points in the commencement of the eruption, had made this absurd 
diagnosis, and, predicting a favorable result, had not thought it necessary to 
repeat his visit. In case of doubt it is the part of prudence to defer making 
a positive diagnosis. A few hours suffice to show the distinctive characters 
of rubeolous and variolous eruptions. But the anxiety of friends often neces- 
sitates the expression of opinion. The absence or lightness of catarrhal symp- 
toms, the earlier appearance of the eruption, and its papular feel under the 
finger in smallpox, enable us to discriminate between the two diseases in the 
commencement of the eruptive stage. Moreover, the symptoms in the initial 
periods are different, as will be seen in our description of smallpox. 

Prognosis. — This is favorable, provided that no serious complication 
arises. With internal inflammatory complication, on the other hand, the 
disease becomes much more grave. A large proportion thus affected die. 
The prognosis is less favorable in feeble children with scanty eruption or an 
eruption appearing at a late period and irregularly. Dyspncea, persistent and 
great acceleration of pulse, and coma indicate an unfavorable ending. Con- 
vulsions occur much more rarely in the course of measles than in scarlet 
fever, and when they occur after the initial period they usually end in coma 
and death. The mortality from measles varies greatly according to the 
severity of the type, but more according to the season, the locality, the sur- 
roundings, and the care which the patients receive, which determine the lia- 
bility to complications. Thus in the cities the mortality is large from measles 
in the hot months among infants, who at this time are very liable to gastro- 
intestinal catarrh. It also seems to be larger in the asylums than in family 
practice. In epidemics in Boston and Pont de l'Arche the mortality was 5 
per cent, of the cases, in Neufchatel, Switzerland, 2 per cent., and among the 
Sioux Indians, at Crow Creek Agency, Dakota, 6.66 per cent. (Therapeutic 
Gaz., July 16, 1888). 

Treatment. — Uncomplicated rubeola requires little medicinal treatment 
except to palliate symptoms. The child should be kept in an airy apartment 
at a uniform temperature of about 70°. A temperature so elevated as to be 
uncomfortable to the nurse is injurious to the patient. But while the popular 
idea is erroneous that he should be kept in a heated atmosphere, it is correct 
that currents of air and sudden reduction of temperature are dangerous. A 
violent and fatal attack of croup occurred in my practice in a girl of fifteen 
in consequence of exposure at an open window at the close of the eruptive 
stage. The diet should be mild, and for the most part liquid. The patient, 
indeed, refuses solid food, but on account of the thirst takes liquids more 
readily. Farinaceous substances, with milk, afford sufficient nutriment in 
ordinary cases. If the previous health have been poor and the vital powers 
reduced, or if there be a complication, more sustaining diet is required. 
Stimulation by wine or brandy is needed in these cases. During the two or 
three weeks succeeding an attack of measles care should be taken to avoid 
exposure to cold or changes of temperature, since during this period there is 
great liability to inflammations of the mucous surfaces. 



MEASLES. 249 

The cough ordinarily requires treatment, inasmuch as the suffering of the 
child and loss of sleep are largely due to this symptom. Demulcent drinks, 
as flaxseed tea. infusion of slippery-elm bark, or solution of gum Arabic, are 
useful, to which, to render them more palatable, lemon-juice may be added. 
A small Dover's powder or the mistura glycyrrhizae composita of the Pharma- 
copoeia, given occasionally, relieves the severity and diminishes the frequency 
of the cough. 

As the chief danger in measles is from inflammation of the respiratory 
organs, local treatment directed to the chest is important. The chest should 
be covered with cotton wadding or in cold weather even oil-silk, unless in 
the mildest cases. This increases the amount of eruption upon the surface 
underneath, and, I believe, tends greatly to prevent complication by capillary 
bronchitis and pneumonia. If the eruption be tardy in its appearance or 
indistinct, it is well to produce moderate counter-irritation by some gentle 
irritant underneath, as camphorated oil, to which in older children a little 
turpentine may be added. 

Affections which complicate measles should receive, for the most part, 
such treatment as is appropriate for them when idiopathic. Secondary dis- 
eases, however, require sustaining measures more than primary. In bronchial 
and pulmonary inflammations — which if they occur early in measles, prevent 
the regular appearance of the eruption, or if in the eruptive stage cause its 
disappearance — prompt counter-irritation over the chest by sinapisms or other- 
wise is required. Trousseau states that he has derived benefit in these cases 
from what he designates urtication. This is produced by stroking the chest 
two or three times daily with the nettle (Urtica dioica or Urtica wrens). This 
causes a prompt and abundant eruption, and with a less amount of suffering 
than one would suppose. The fever abates, and the respiration becomes more 
natural in proportion to the amount of nettlerash. On the second day the 
effect is less than on the first, and after three or four days, says Trousseau, 
no further irritation results from the nettle. When counter-irritation is pro- 
duced, by whatever method, the chest should be covered with a warm and 
soft poultice, as the ground flaxseed ; derivatives to the extremities are useful 
in such cases. In capillary bronchitis and pneumonia stimulating expectorants 
are required, as carbonate of ammonium. I frequently write the following 
prescription. It is useful both as an expectorant and cardiac stimulant. 
Given in milk or after food is taken, it does not produce gastritis, as it often 
does in a more concentrated form : 

R. Ammon. carbonat., gr. xvj-^ss ; 

Aquae purse, ^ij. 

Give one teaspoonful in three or four of milk every hour or two. 

Chloride of ammonium is also a good remedy in these cases, employed in 
double the dose of the carbonate. 

Quinia to reduce the fever and digitalis or strophanthus or camphor as a 
heart tonic are also very useful in these inflammations, given alone or alter- 
nately with the above. 

The cases of gangrenous vulvitis alluded to above were treated with a flax- 
seed poultice, and iodoform dusted over the surface each day or second day. 
with a satisfactory result. As regards the treatment of other complications 
the appropriate measures are detailed elsewhere. 



250 CONSTITUTIONAL DISEASES. 

CHAPTER II. 
SCARLET FEVER. 

It is supposed by some who have studied the history of scarlet fever that 
it is of ancient origin, but the descriptions of diseases left us by the old writers, 
and by those in the Christian era until after the Middle Ages, are so obscure 
or differ so widely in the statements made from the symptoms of scarlet fever 
as it occurs in modern times that the impartial critic fails to find any clear 
evidence of its occurrence prior to the last four or five centuries. 

The first clear and undoubted portrayal of this disease is found in the 
medical literature of the sixteenth century. Sydenham and his contemporaries 
in the seventeenth century witnessed epidemics of it and studied its nature 
more thoroughly, and consequently acquired a more accurate knowledge of it 
than that possessed by their predecessors. It was in this century that measles 
and scarlet fever were differentiated. During the last two hundred years 
scarlatina has been the subject of monographs too numerous to mention. It 
has long been regarded as one of the most important maladies of childhood, 
on account of its frequency and the great mortality that attends it, so that 
numerous cases and many epidemics are every year related in the medical 
journals. By this vast accumulation of observations and the patient and 
thorough use of the microscope our knowledge of scarlet fever has become 
full and accurate. 

As with most of the infectious maladies, scarlet fever was introduced into 
the Western Hemisphere by European navigators. It was brought to North 
America about the year 1735. Tardily it spread to South America, where it 
appeared in 1829, and more recently it has been established in Australia. 
It entered Iceland in 1827 and Greenland in 1847. 

Etiology. — As yet, observers do not agree in regard to the parasite 
which is supposed to sustain a causal relation to scarlet fever. Klebs states 
that it is highly probable that both measles and scarlet fever are produced by 
micrococci, and he has sketched the design and described the development of 
a microbe which he designates the Monas scarlatinosum. 

The London Medical Times and Gazette for Jan. 28, 1882, contains an account 
of the supposed discovery of the scarlatinous microbe by Eklund of Stockholm, an 
authority in the microscopic examination of parasites. He says that scarlet fever 
is rarely absent from the Swedish capital and from the barracks and dwellings on 
the Isle of Skeppsholm. In the urine of scarlatinous patients he has constantly 
found a prodigious number of discoid corpuscles, oval or round, their diameter 
being less than i^^oo millimetre, and from -^ to ^ that of a red blood-cell. They 
are colorless or yellowish-white, surrounded by a distinct cell-wall, each containing 
a well-defined nucleus of a deeper hue. Sometimes one, sometimes more, of them 
are seen in the field of the microscope. They exhibit rotary or oscillatory move- 
ments, especially observed when a drop of water is added to the fluid. 

In 1886, Dr. Edington of Edinburgh isolated a diplococcus and a bacillus from 
the blood and epidermis of scarlatinous patients. He states that inoculation of the 
bacillus in rabbits caused erythema, followed by desquamation. But these obser- 
vations, as detailed in the Lancet, show possible sources of error, and have therefore 
attracted but little attention. 

Dr. E. 0. Shakespeare describes the bacillus scarlatinas of Edington as "rods 
measuring 0.4 m. in thickness and 1.2 m. to 1.4 m. in length, most usually forming 
excessively long-pointed and curved leptothrix filaments, motile ;" and he" remarks, 
" It is pretty well proven that this bacillus scarlatinse is the specific cause of scarlet 
fever." 1 

1 Annual of Med. Sci., vol. v., 1888. 



SCARLET FEVER. 251 

Whatever may be the micro-organism which causes scarlet fever, its mode 
of action and effects have been ascertained by clinical observations. Without 
doubt, it commonly enters the system by the breath, but it probably may 
enter in the ingesta, and it infects the blood. That it resides in the blood has 
been ascertained by inoculation with this liquid, by which scarlet fever has 
been reproduced in its typical form. From the blood it enters the tissues 
and secretions. Hence handkerchiefs or linen containing the saliva or mucus 
of a patient, the epidermic scales shed abundantly in the desquamative period, 
and probably also the urinary and fecal evacuations, contain the poison, so as 
to be highly infectious. Even the discharge of a scarlatinous otorrhcea is 
thought by some to be contagious for a considerable time. 

Scarlatina is communicable not only by direct exposure to a patient, but 
also by exposure to objects which happen to be in his room during his illness, 
and to which the poison becomes attached, such as clothing, books, and toys ; 
small packages, as we have stated above, sometimes convey and disseminate 
the contagious principle. 

Observations have been made which show that scarlatina has been communi- 
cated by infected milk. The following instance was published in a British journal : 
Scarlet fever occurred in the family of a milkman, and the milk, before it was dis- 
tributed, remained for a time in a kitchen which had been occupied by the patients. 
This milk was taken by twelve families, and in six of these scarlatina occurred 
almost simultaneously at a time when few cases were occurring in the locality. 
There had been no direct exposure to the carrier of the milk nor to members of the 
affected family (Taylor). In another instance a woman and her son had scarlet fever 
while they were serving milk to several families, and the disease appeared in all 
these families except one, which consisted of old people (Bell). It is known that 
milk absorbs volatile substances so as to be flavored by them, and is shown in the 
experiment of placing it in an open vessel in a box with a pineapple; and it may 
in a similar manner become infected by the specific principle of scarlet fever, or it 
may be infected by detached particles of epidermis ; which is not improbable when 
one convalescing from scarlet fever is allowed to milk the cows or prepare the milk 
for distribution. In 1885 an epidemic of scarlet fever in London was traced to the 
milk-supply coming from a certain dairy in Hendon. The health officer of Hendon 
discovered a contagious disease in the cows of this dairy communicable to healthy 
cows by inoculation from the teats, and also communicable to man. The symptoms 
in the cow were fever, cough, sore throat, discharge from nostrils and eyes. Com- 
municated to man, the disease produced malaise, and in four or five days a vesicle. 
Crookshank believes that the Hendon disease was the Jennerian cowpox, and the 
symptoms certainly bore a closer resemblance to cowpox than to scarlet fever. 
Probably, therefore, the scarlet fever in London originated from some other source 
(London Lancet). 

The scarlatinous virus surpasses that of any other eruptive fever except small- 
pox in its tenacious attachment to objects and its portability to distant localities. 
Hence in the literature of the disease are the records of many cases in which the 
poison was conveyed long distances, retaining its virulence to the full extent and 
causing an outbreak of the malady in the localities to which it was carried. In 
New York, so frequently has scarlet fever as well as measles and diphtheria been 
contracted from the persons or clothing of well children who come from infected 
houses, that the Health Board now exclude from the public schools all children 
who come from such houses, even though they live on separate floors from those 
occupied by the sick. In one instance that came under my notice a washerwoman 
whose child had scarlet fever communicated the disease to an infant in the house- 
hold where she was employed, by placing her shawl over the cradle in which it 
was lying. A physician of my acquaintance went from a scarlet-fever patient ro a 
family several streets distant, and took one of the children upon his lap. After the 
usual incubative period this child sickened Avith a fatal form of the malady, and 
the remaining children of the household were in time affected. In New York scar- 
let fever has seemed to me to be not infrequently communicated through school- 
books, which, profusely illustrated by pictures and rendered attractive to the young. 
are often allowed to lie upon the bed of a scarlatinous patient, and be handled by 



252 CONSTITUTIONAL DISEASES. 

him during convalescence or even during the course of the fever if it be mild. The 
young librarian of the circulating library of a Sunday-school, whose pupils came 
largely from the tenement-houses, was occupied a considerable part of a day in 
covering and arranging the books. After about the usual incubative period of scar- 
let fever he sickened with the disease. His two sisters were immediately removed 
to a rural township three hundred miles away, and to an isolated house where scar- 
latina had never occurred. About one month after his recovery, and after his room 
had been disinfected by burning sulphur and his bedclothes and linen had been 
thoroughly washed, and all articles suspected to hold the poison had been either 
disinfected or destroyed, the brother visited his sisters in the country. Three weeks 
subsequently to his arrival one of these sisters sickened with scarlet fever, and a 
week later the other also. It seems that the exposure must have occurred several 
days after his arrival in the country from some books or other infected article in 
his possession. About two months elapsed after the last case : the family had 
returned to the city, the infected room in the country-house had been thoroughly 
fumigated by burning sulphur from morning till evening, when a little girl from 
an inland city remained a few days in this house, and probably often entered the 
room where the young ladies had been sick. In a few days she also sickened with 
a fatal form of scarlatina. Such histories and experiences are not infrequent. They 
are common during epidemics of scarlet fever. They indicate an extraordinary 
attachment of the scarlatinous poison to objects, and show that it is not gaseous 
nor readily volatilized. 

A striking example of this fixity of the poison occurred in the practice 
of the late Kearney Rogers, formerly a prominent and much-esteemed sur- 
geon of New York City. Six children in a family had scarlet fever. Three 
and a half months subsequently another child, living at a distance, was 
allowed to return home and occupy the apartment in which the sickness 
had occurred. One week subsequently to the date of the return this child 
sickened with the same malady. Elliotson states that a patient with scarlet 
fever was admitted into one of the wards of St. Thomas's Hospital, and for 
two years subsequently young persons who were admitted into the ward 
were apt to take the disease. Richardson of London relates the following 
experiences of a family whom he attended in the rural district : "At a short 
distance from one of our villages there was situated on a slight eminence a 
small clump of laborers' cottages, with the thatch peering down on the beds 
of the sleepers. A man and his wife lived in one of these cottages with four 
lovely children. The poison of scarlet fever entered the poor man's door, and 
struck down one of the flock." The remaining children were now removed 
some miles away, and after several weeks one of them was allowed to return. 
Within twenty-four hours he also took the disease, and quickly died. The 
walls of the cottage were now thoroughly cleaned and whitewashed, the floors 
scoured, and all the wearing apparel either destroyed or washed. Four months 
elapsed after the last sickness when one of the remaining children returned. 
" He reached his father's cottage early in the morning ; he seemed dull the 
next day, and at midnight I was sent for. to find him also the subject of 
scarlet fever. The disease again assumed the malignant type, and this child 
died." Richardson believes that the contagion was attached to the thatch, 
which could not be thoroughly disinfected. The fact of this remarkable long- 
continued attachment of the poison to objects, indicating by this fixity that 
it is a solid, is consonant with the theory that it is an organism. 

Incubative Period. — The duration of the incubative period varies in 
different cases. It is sometimes less than twenty-four hours, as in the above 
case reported by Richardson ; in the following well-known case, observed by 
Trousseau, it was one day : A girl arrived in Paris from Pau, where there was 
no scarlet fever, and occupied the same apartment with her sister, who was 
sick with this disease. Twenty-four hours after her arrival she was also 
attacked with the same malady. 



SCABLET FEVER. 253 

Russeberger attended a child who was exposed at noon to scarlet fever, 
and took the disease on the following night. B. W. Richardson (Clinical 
Essays, 1S61. vol. i. p. 94) gives his own experience. He had applied his ear 
to the chest of a patient suffering from scarlet fever, and was conscious of a 
peculiar odor emitted from the patient. He was immediately nauseated and 
chilly, and from that moment he dated the beginning of an attack of scarlet 
fever. In the Transactions of the Clinical Society of London, vol. ix., 1878, 
the late Charles Murchison gives the statistics of 75 cases showing the incu- 
bative period, as follows : 

In 4 cases it was not more than . 24 hours. 

" 2 " " " " 30 " 

" 3 " " " " 36 " 

" 4 " " " " 40 " 

it j it a u u . 41 " 

" 4 " " " " 58 " 

" 1 " " " " 54 " 

" 1 " " " " m 2Jdays. 

" 31 cases it was within (time not accurately ascertained) ... 4 " 

" 2 cases the incubation did not exceed 4i " 

" 17 " " " " " 5 " 

n 9 " u " " " A " 

In 3 cases Murchison believes that the incubation was precisely fixed at 
thirty-six hours, three days, and four and a half days. 

Watson says that a man reached Devonshire at mid-day to see his daugh- 
ter, who had scarlet fever. Two days later he was also attacked. Rehn saw 
a child who was attacked two days after its grandmother returned from a 
case of scarlet fever ; and Zengerle, a girl of ten years, residing at Wangen, 
where there was no scarlet fever, who took the disease two days after her 
mother had returned from visiting a family affected with it. Loochner states 
that a boy aged four and a half years was attacked one and a half days after 
admission into the infected wards of an hospital. Armistead, in his annual 
report on the health of the Newmarket rural district, states that three chil- 
dren, coming from a different part of the district, visited Wesley, and stayed 
next door to a child who had had scarlet fever six weeks previously, and who 
was allowed to play with these children on the evening of August loth and 
morning of the 14th. The family then returned home, and on the 18th. four 
days after the exposure, all three children sickened with scarlet fever (British 
Medical Journal, September 30, 1882). 

Ordinarily, therefore, the incubative period, though varying in different 
cases, is within six days. Many cases, however, occur in which it seems to 
be longer. Thus, in my practice scarlet fever appeared in a family on April 
26, 1882. The patient was immediately removed to the third floor and the 
other children to the basement. All communication between the infected 
room and the basement was forbidden, but on May 8th, twelve days alter the 
separation, one of these children sickened with the disease. Many observers. 
among whom may be mentioned Niemeyer and Copland, believe that the incu- 
bative period may be longer than one week, but on account of the subtlety 
of the poison and the many modes of transmission, it is possible that in the 
instances of an apparently long incubative period there were other and unsus- 
pected exposures. When scarlet fever has been communicated by inoculation, 
as in the experiments of Eostan and others, the incubative period has been 
about seven days, but Gerhardt states that a man was attacked four days 
after an abscess was opened by a knife used upon a scarlatinous patient. 
This variation in the incubative period, which also occurs in some other infec- 
tious diseases, as diphtheria, is probably due mostly to individual differences, 



254 CONSTITUTIONAL DISEASES. 

some being more susceptible than others ; but it may be due partly to those 
obscure meteorological conditions which we designate the epidemic influence. 
Probably, as a rule, when the disease is quickly developed after exposure the 
attack is more severe than when several days elapse. 

Contagiousness. — The area of the contagiousness of scarlet fever is 
small : it apparently embraces only a few feet. Therefore, close proximity 
is the necessary condition of its propagation. Hence many who are exposed, 
particularly of those who are remotely exposed, do not contract the disease. 
There is also an idiosyncrasy in some children, so that they resist infection 
even when repeatedly and closely exposed. In the New York Medical Record 
for March 23, 1878, C. E. Billington states that of 90 children in 26 families 
who were exposed to scarlet fever, 43 contracted the disease and 47 escaped ; 
whereas, as is well known, comparatively few unprotected children escape 
pertussis, variola, varicella, or measles if exposed to either of these diseases. 
By strict isolation, therefore, the spread of scarlet fever is more easily pre- 
vented than that of most other acute infectious maladies. In the New York 
Foundling Asylum for a number of years children with scarlet fever were 
isolated in a small room attached to one of the wards. The door between 
the two rooms was closed, and not opened during the continuance of the 
sickness. Entrance into the small room was through another door, and a 
nurse was assigned to the scarlet-fever cases, with strict directions that she 
should not mingle with the other children. These simple precautions were 
found sufficient in the various epidemics of scarlet fever which occurred in 
the city to prevent the spread of the malady through this institution ; whereas, 
similar measures were much less effectual in arresting the spread of measles 
and pertussis. Consequently, an outbreak of scarlet fever in this institution 
was usually limited to a few cases, while the extension of measles and pertus- 
sis was arrested with difficulty till a more efficient quarantine was established. 

Variations in Type. — The type of scarlet fever varies greatly in different 
epidemics, and frequently also in cases which occur in the same epidemic, even 
in the same family. One child may have scarlatina so mildly that little treat- 
ment is required and convalescence soon begins, while another has the malig- 
nant form, and soon succumbs, notwithstanding the prompt employment of 
the most efficient and appropriate measures. Ordinarily, however, if the first 
case in a family be very severe, subsequent cases will present a similar type ; 
but there are notable exceptions. This variation in type in different years and 
different epidemics is probably not equalled in any other infectious malady. 
Consecutive epidemics may present this variation, or the same type may con- 
tinue for a series of years, and then, from some unknown cause, change to 
one milder or more severe. In England, during Sydenham's life, scarlet fever 
was so mild that he regarded it as a trivial affection, requiring little attention, 
like rbtheln of the present time ; but after the death of Sydenham, Morton 
and his contemporaries in London found, to their sorrow, that the type of 
scarlet fever was very different from that described by Sydenham's pen. The 
late Dr. Graves of Dublin and his contemporaries treated a mild type of scar- 
let fever with a very small percentage of deaths — much less than that during 
the preceding generation — and they attributed their success to their greater 
knowledge and more appropriate use of remedies than their ancestors pos- 
sessed and employed. By and by the type changed, the mortality of former 
years was restored, and they discovered that their previous success in saving 
life had been due not to their skill, but to the mild form of the malady. A 
distinguished physician of Xew York treated more than fifty cases of scarlet 
fever in one of the institutions without a single death. A few months after- 
ward the type of the malady changed, and his own son perished from it. 

The diseases known as surgical scarlatina and obstetrical scarlatina are certainly 



SCARLET FEVER. 255 

at times a true scarlet fever, but it is probable that the pathological states to which 
these terms have been applied have in most instances been cases of septicaemia or 
blood-poisoning with accompanying dermatitis so common in surgical and obstetrical 
practice. The following were cases of the kind alluded to. They occurred in Guy's 
Hospital, and were published by H. G. Howse in Guy\s Hospital Reports for 1879 : 
On March 15, 1878, Jacobson performed osteotomy upon a child suffering from ex- 
treme rachitis. The operation was followed by a moderate febrile movement (100° 
to 101°). and after three days by the appearance of an efflorescence, with sore throat 
and the strawberry tongue. The osteotomy had been performed under carbolic-acid 
spray and with all the details of antiseptic surgery. The rash soon faded, the tem- 
perature fell, and the child, temporarily separated from the other patients from the 
suspicion that the disease was scarlet fever, was brought back to the ward. The 
subsequent history confirmed the diagnosis of scarlet fever, for the skin desqua- 
mated, and on April 1st abundant albumen was found in the urine. The case ter- 
minated favorably. Three months previously the same operation had been per- 
formed on the other leg, with no unfavorable symptoms. On April 5th, three weeks 
after the osteotomy, a lipoma was removed from another patient aged twenty-one 
years. The following day the temperature rose to 101°, and remained at that till 
April 8th. when it suddenly increased to 103°, and a rose-rash occurred over the 
body, with sore throat. On April 9th, Howse excised the elbow-joint of a girl of 
sixteen years having pulpy disease. On the 10th her temperature began to increase, 
and on the 11th reached 105.8°. Toward evening a roseoloid eruption appeared 
ovei her body, and she was isolated. On April 12th, Dr. H. excised a fibroid bursa 
patellae from a woman of twenty-nine years. On the following day her temperature 
was 99°, but on the 14th it rose to 100°, and on the evening of the 15th she had 
rigors and headache. On the morning of the 16th the temperature was 102.5°, and 
a roseoloid eruption occurred over the face and chest. The surgeons now perceived 
that an epidemic of the so-called surgical scarlatina was occurring, so as to justify 
the postponement of other operations. 

In the same volume of Guy's Hospital Reports, James F. Goodhart gives the 
histories of nearly thirty cases of this disease occurring during a series of years in 
the same hospital. The patients were chiefly children, having the most diverse 
surgical ailments, among which may be mentioned hip disease and abscess, genu 
valgum without operation, necrosis of femur, hydrocele with explorative operation, 
a scald, a sinus over the great trochanter, spinal disease with abscess, tenotomy for 
club-foot, and vesical calculus with operation. The most common disease was caries 
or necrosis with abscess. In cases operated on the intervals between the operations 
and the occurrence of the efflorescence varied from two days to more than two weeks. 
Goodhart, after a careful examination of these cases, came to the conclusion that 
they were for the most part examples of true scarlet fever, especially as a consider- 
able proportion of them occurred in groups, and there was a known exposure of 
some of the patients to children admitted into the hospital with the sequelae of 
scarlet fever. 

In the British Med. Jour, for Jan., 1879, George May, Jr., reported a case of 
efflorescence in surgical practice which appears to have been scarlatinous. A child 
was operated on for the radical cure of hernia on Dec. 4th. Toward the close of 
the same day he became restless, vomited, and his pulse on the following day rose 
to 136. Forty-eight hours after the operation a rash appeared on the chest and 
arms, the abdomen became tense and painful, and on the following day he died. 
The poison, however, in this case may have been septic. 

Hillier remarks {Diseases of Children): " In the hospital for sick children, of 
the children who contract scarlatina a very large proportion have been the subjects 
of a surgical operation within a week before the rash appears." Gee says (Rey- 
nolds's System of Medicine) : " It has been doubted by some whether the scarlatini- 
form rash which sometimes follows operations is really scarlatinal. The eruption 
appears from the second to the sixth day after the operation, and, in the eases which 
have caused the doubt, is very fugitive and the first and only symptom. Yet that 
the disease really is scarlet fever would seem to be proved by the following observa- 
tions : first, that the disease occurs in epidemics -, secondly, that in a given epidemic 
a severe case occasionally relieves the monotonous recurrence of the very mild form : 
thirdly, that a precisely similar scarlatinilla attacks in the same epidemic patients 
who have not been subjected to operation and who have no open sores ; and lastly. 
by way of a veritable experimentum crucis, that, however freely the patients are 



256 CONSTITUTIONAL DISEASES. 

exposed to ordinary scarlet-fever contagion afterward, they do not contract that 
disease." Paget and other distinguished London surgeons who have observed this 
complication of surgical cases believe that the patients have been previously" exposed 
to the scarlatinous poison, and that the surgical diseases or operations furnish favor- 
able conditions for the occurrence of scarlet fever, so that the exposure, which prob- 
ably would have been without result in ordinary health, causes an outbreak of the 
malady. 

Those who have reported cases of this form of efflorescence have for the most 
part neglected to state whether the patients had had scarlet fever previously, know- 
ledge of which would have aided in the diagnosis ; but from an examination of the 
histories of cases, especially those published in the London journals in the last four 
or five years, there can, I think, be little doubt that surgical maladies of a certain 
kind, especially traumatism, do produce a state of system which predisposes to 
scarlet fever, so that this class of patients are especially liable to contract it. There- 
fore, in my opinion, a considerable proportion of reported cases of surgical scarla- 
tina are genuine, but in a considerable number, perhaps an equal number, of such 
cases the histories and symptoms indicated a septic rather than scarlatinous efflores- 
cence, and in not a few instances, when consultations have been held, opinions dif- 
fered, some diagnosticating scarlet fever, others septicaemia. In some of the cases 
I find it stated that the fauces presented the normal appearance. Now, faucial red- 
ness is so generally present in scarlet fever, antedating that of the skin and coex- 
isting with it, that its absence is strong evidence that the disease is not scarlatinous. 
Moreover, when, as was true of certain of the reported cases, the rash appeared 
irregularly upon the surface, and faded away in two or three days with the abate- 
ment of the fever, and the conditions of septic absorption were present, the efflores- 
cence was probably septicsemic. 

The following were apparently cases of septicEemic efflorescence : A child aged 
five years {Brit. Med. Jou?\, Feb. 15, 1879) had inflammation of the lymphatic 
glands in the groin, which suppurated. At the time when the abscess was fully 
formed a rash appeared over the entire body. It consisted of numerous red points, 
but was paler than that of ordinary scarlet fever ; temperature never above 99° : no 
sore throat nor desquamation of cuticle. No child exposed to her took scarlet fever, 
and her sickness could not be traced to infection. In the British Med. Jour., Jan. 4, 
1879, L. Braxton Hicks states that his son, attending school at Reading, was seized 
with a severe attack of pyrexia, accompanied on the second day by delirium and the 
occurrence of a rash-like scarlet fever over the entire surface. He had no decided 
redness of the fauces, though it was perhaps slightly flushed. The right buttock 
was swollen from inflammation, and a large, deep-seated abscess formed near the 
tuberosity of the ischium. When the delirium abated the boy said that he was 
standing the day before the fever began with his legs far apart, when a schoolfellow 
stretched them farther by suddenly pulling on one of them. The rash, which was 
nearly universal, lasted three days, and was not followed by desquamation. No 
case of scarlet fever occurred in the school before or afterward. In the same volume 
of the British Medical Journal. Surgeon Frolliott, of the East India Service, relates 
the case of a private, aged twenty-three years, and three years in India, who, when 
on duty in the Punjab, was injured by the explosion of an Afghan powder-magazine. 
The accident occurred Dec. 21, 1878. On Dec. 25th a bright scarlet rash appeared 
upon the abdomen and spread over the entire body. The following day the erup- 
tion was very vivid, like a boiled lobster, and it lasted five days. The temperature, 
which in the beginning had been 101°, abated to the normal after the rash appeared. 
No soreness of throat nor redness of the buccal surface occurred, but the epidermis 
desquamated, even from the palms of the hands and soles of the feet. Now, the 
febrile movement of scarlet fever does not cease while the efflorescence is distinct. 
It does not even diminish when the eruption appears, while in the above case it fell 
to the normal — a common occurrence in septicaemia, even when the blood-poisoning 
is profound. Moreover, scarlet fever is so rare in India that Frolliott, after twelve 
years' service, had onlv - heard of one case among Europeans and natives. The 
surgeons who consulted over the case of this private disagreed in opinion, some 
regarding the disease as septicaemic, others as scarlatinous. But a better knowledge 
of the clinical history of scarlet fever on the part of these army surgeons would, 
I think, have removed all doubt as to the diagnosis. 

It is the opinion of some reputable surgeons that the exposure of traumatic 
patients to the scarlatinous poison sometimes aggravates the inflammation of 



SCARLET FEVER. 257 

wounds, causing them to assume an unhealthy appearance, even though no scarla- 
tina be produced. The late Dr. Solly made the remark, "Whenever a case of 
surgery in private practice takes on a highly phlegmonous appearance, I am always 
sure to find break out. in the inmates of the house, either erysipelas or scarlet 
fever" (British Med. Jour., Feb. 15, 1879). We will see that the scarlatinous 
poison sometimes causes pharyngitis or nephritis without producing the general 
disease. In a similar manner it seems that it may aggravate open wounds, intensi- 
fying the inflammation in them, while there is no efflorescence or other symptom to 
show that scarlatina itself is present. The poison appears to act entirely locally in 
such cases. 

Paget, in his Clinical Lectures, says: "I think it not improbable that in some 
cases results occurring with obscure symptoms within two or three days after opera- 
tions have been due to the scarlet-fever poison, hindered in some way from its usual 
progress."' Playfair, in his remarks on the puerperal state, adds: "Mr. Spencer 
Wells informs me that he has seen cases of surgical pyaemia which he had reason to 
believe originated in the scarlatinal poison ; and his well-known success as an ova- 
riotomist is no doubt, in a great measure, to be attributed to his extreme care in 
seeing that no one likely to come in contact with his patients has been exposed to 
any such source of infection. " Opinions like these, held by such prominent mem- 
bers of the profession and sustained by many observations, should certainly induce 
physicians to prevent, as far as possible, exposure of their surgical patients, espe- 
cially if they have sores or wounds, whether by traumatism or scalpel, to the scar- 
latinal poison. 

Women during convalescence after childbirth are very liable to contract scarlet 
fever. In the New York Infant Asylum, which has maternity wards, a woman was 
admitted from a house in which scarlet fever was prevailing, and assigned to a cot 
next that occupied by one of the waiting-women, who was confined soon afterward. 
Her labor was favorable, but three days afterward she took scarlet fever, and another 
lying-in patient contracted it from her. The sore throat and desquamation were 
characteristic. It has come to my knowledge that a physician of New York, in 
whose family scarlet fever was occurring, attended three women in succession in 
their confinement, and all contracted scarlet fever, which presented the character- 
istic symptoms, and two of them died. Experienced and cautious physicians of 
New York, aware of the danger, do not go directly from a scarlatinous patient to an 
obstetrical case, but avoid the risk by intermediate visits to other patients or by 
remaining for a time in the open air. As an additional precaution, I never attend 
a case of midwifery without first soaking my fingers in a solution of corrosive subli- 
mate. 

Playfair, remarking on this subject, says : " There is good reason to believe that 
the contagium of zymotic diseases may produce a form of disease indistinguishable 
from ordinary puerperal septicaemia, and presenting none of the characteristic fea- 
tures of the specific complaint from which the contagium was derived. This is 
admitted to be a fact by the majority of our most eminent British obstetricians, 
although it does not seem to be allowed by continental authorities, and it is strongly 
controverted by some writers in this country. It is certainly difficult to reconcile 
this with the theory of septicaemia, and we are not in a position to give a satisfac- 
tory explanation of it. I believe, however, that the evidence in favor of the possi- 
bility of puerperal septicaemia originating in this way is too strong to be assailable. 
The scarlatinal poison is that regarding which the greatest number of observations 
has been made. Numerous cases of this kind are to be found scattered through our 
obstetric literature, but the largest number are to be met with in a paper by Braxton 
Hicks. Out of 68 cases of puerperal disease seen in consultation, no less than 37 
were distinctly traceable to the scarlatinal poison. Of these, 20 had the character- 
istic rash of the disease, but the remaining 17, although the history clearly proved 
exposure to the contagium of scarlet fever, showed none of its usual symptoms, and 
were not to be distinguished from ordinary typical cases of the so-called puerperal 
fever. On the theory that it is impossible for the specific contagious diseases to be 
modified by the puerperal state, we have to admit that one physician met with 17 
cases of puerperal septicaemia in which, by a mere coincidence, the contagion of 
scarlet fever had been traced, and that the disease nevertheless originated from some 
other source — an hypothesis so improbable that its mere mention carries its own 
refutation." 

Parturition, like traumatism, furnishes in an eminent degree the conditions in 

17 



258 



CONSTITUTIONAL DISEASES. 



which septic poisoning occurs, and the efflorescence which often accompanies septi- 
caemia bears, as we have seen, a very close resemblance to that of scarlet fever. 
Hence in many instances the same difficulty is present in making a differential diag- 
nosis between septic and scarlatinous blood-poisoning in obstetrical cases which 
occurs in surgical practice. But, according to my observations, an efflorescence 
occurring during the week following parturition is in most instances septic. It is 
only in exceptional cases that it is scarlatinous. But if, as Playfair believes, the 
scarlatinal poison sometimes produces in parturient women a puerperal fever in 
which the characteristic scarlatinal symptoms are lacking, and which, in the present 
state of our knowledge, is not distinguishable from ordinary septic fever, certainly 
the scarlatinous virus sustains a more frequent causal relation to childbed fever than 
has been heretofore supposed. 

Age. — Infants under the age of six months do not ordinarily contract 
scarlet fever, although fully exposed, and those under four months nearly 
possess immunity. Still, this disease has been observed in new-born infants, 
contracted, apparently, through the placental circulation. Tourtual states 
that a woman waited upon her own husband and child, both of whom had 
scarlet fever, during the eighth and ninth months of her pregnancy till near 
her confinement. Though she had no symptoms of scarlet fever, her infant 
had unusual redness of the skin and buccal surface and difficulty of swallow- 
ing up to the fifth day. On the ninth day desquamation began, and at a 
later stage the nails of the fingers and toes separated. A case having a his- 
tory in some respects similar is related by Megnert, but the symptoms were 
anomalous for scarlet fever, and the disease may have been ordinary septic 
fever. On the other hand, in one instance in my practice a mother had scarlet 
fever, beginning about the third day after her confinement, and although she 
suckled her infant and it was constantly in bed with her, it had no symptoms 
of scarlet fever, but became affected immediately afterward by a severe form 
of eczema, probably from the altered quality of the milk : and in two instances 
observed by Murchison new-born infants remained healthy, although their 
mothers suffered from scarlet fever. 

After the age of six months the liability to scarlet fever increases till the 
close of infancy, children between the ages of six months and one year being 
less liable to contract the malady than during the second year, and those in 
the second year being less liable to it than those in the third year. Murchison 
collected the statistics of deaths from scarlet fever in England and Wales 
during a series of years ending with 1861. The number of deaths aggregated 
148,829, and the percentage of deaths at different ages was as follows : 



Deaths under 1 year . 

between 1 and 

2 and 



" 3 and 4 
" 4 and 5 
5 and 10 
" 10 and 15 
" 15 and 25 
" 25 and 35 
over the age of 35 



6.7 per 

2 years 14.09 

00 

13 

9 

9 



cent. 



16. 
15. 
11. 

25. 

5. 
2. 
0. 
0. 



Among the deaths were 10 cases above the age of 85 years, so that scarlet 
fever, though especially a disease of childhood, may occur in any decade of 
life; but old age, like early infancy, almost possesses immunity from it. 

I have preserved the records of the ages of 145 consecutive cases occurring 
in private practice. If we add to these 58 cases observed by Prof. Octerlony 
(Amer. Journ. of Med. Set., July, 1882), we have the statistics of the ages 
of 203 cases, which are embraced in the following table : 



SCARLET FEVER. 259 

Under 1 year 3 

From 1 to 2 years t ... 25 

" 2 to 3 " 43 

" 3 to 5 " 57 

" 5 to 10 " 53 

" 10 to 15 " 13 

" 15 to 20 " 3 

" 20 to 30 " 4 

" 30 to 40 " 2 

Total 203 

Clinical Facts regarding Scarlet Fever. 

As a rule, scarlet fever occurs but once, one attack conferring immunity 
from the disease for life ; but there are exceptions. 

In 1860, I attended a child with fatal scarlet fever who three years previously, 
it was stated, had passed through a first attack with all the characteristic symptoms. 

The following case occurred in a family attended by the late Dr. Herzog : II , a 

boy of six years, had scarlet fever in a mild form in January and February, 1875, 
followed by moderate desquamation. In July of the same year he was kicked by a 
horse in the street, receiving a deep scalp-wound which required stitching. Three 
days afterward he had, to appearance, a second attack of scarlet fever, attended by 
high febrile movement and followed also by desquamation. It was believed by 
Dr. H. to be a genuine case, and was so treated. I am not able to state as regards 
the presence of soreness of the throat, and doubt arises whether the second attack 
may not have been septicsemic. In April, 1876, a third attack occurred, which I 
saw from the beginning. It was accompanied by all the characteristic symptoms — 
injection of the fauces, an efflorescence continuing the usual time, followed by des- 
quamation and albuminuria, the latter remaining several weeks. Richardson states 
that three distinct attacks occurred in his own person, and a student attending the 
lecture at which this was mentioned informed the doctor that he also had scarlet 
fever three times. 

Sometimes a second attack occurs so soon after the first that it has been described 
as a relapse. The following was a case in point in the practice of Godneff (Meditz. 
Vestnik, No. iv., N. Y. Med. Rec, April 30, 1881): A youth of seventeen years 
contracted scarlet fever while taking care of a child. It began with a chill, and he 
had the usual efflorescence, sore throat, and tumefaction of the cervical glands. An 
exudation appeared upon his tonsils and uvula, and his temperature reached 104°. 
The urine contained a trace of albumen ; the rash in due time faded ; and the epi- 
dermis exfoliated. On the fifteenth day, when he was about ready to leave the hos- 
pital, he again had a chill, followed by fever. The temperature reached 105.2°, the 
rash reappeared over the entire surface except the face, diphtheritic exudations 
occurred upon the fauces, and the urine, the quantity of which was diminished, 
again became albuminous. The second efflorescence faded on the twenty-fourth day, 
and on the twenty-seventh exfoliation began. Hillier says : "I have seen a young 
woman in the fever hospital suffering from a second attack of scarlatina, the first 
attack having occurred five weeks previously. She had quite recovered from her 
first illness, and was acting as nurse. In both seizures the rash, the sore throat, and 
other symptoms were characteristic. The relapse or recurrence was less severe than 
the primary disease. 1 ' Cases of a fourth attack, or even of a greater number, have 
been reported. The first seizure is sometimes milder, but in other instances is more 
severe, than those which follow. 

Exposure to the scarlatinous poison not infrequently produces pharyngitis with- 
out the occurrence of scarlatina, and the inflammation is usually severe, accompa- 
nied by pain in swallowing and marked febrile movement. This phlegmasia is 
distinguished from scarlet fever by its shorter duration and the absence oi' the efflor- 
escence. It occurs in adults as well as in children, and in those who have had. as 
well as in those who have not had, scarlatina. So far as 1 have heard, it is very 
seldom accompanied or followed by any of the complications or sequelae so common 
in and after scarlet fever. It cannot be distinguished from ordinary pharyngitis 
except in the manner in which it occurs, and one attack does not preclude another. 
The late George B. Wood made the remark that he never attended a ease of scarlet 



260 CONSTITUTIONAL DISEASES. 

fever without suffering from sore throat. The following were examples of this form 
of pharyngitis : On Jan. 17, 1882. I was called to a boy of three years with severe 
scarlet fever, ushered in by convulsions. On the following day his sister, aged seven 
and three-fourths years, whom I had attended a year previously during a severe 
attack of scarlatina, and who had been almost constantly with the brother, became 
very ill, with a temperature of 103.5°. Examination revealed severe inflammation 
of the fauces, without pseudo-membrane or any other exudation except muco-pus. 
On Jan. 19 an older brother, nine years, whom I had attended in scarlet fever three 
years previously, was affected in the same way, his temperature being 104° and his 
respiration guttural and noisy, especially during sleep, in consequence of the great 
amount of faucial swelling. At times he was delirious. The inflammation in both 
cases began to abate about the third day, and had disappeared by the close of the 
week. That the contagium of scarlet fever may be received into the system and 
cause pharyngitis while the patient has immunity from scarlet fever through a pre- 
vious attack, and that this inflammation may occur any number of times, as in the 
case of Dr. Wood, are remarkable facts. 

Now and then cases occur which appear to show that the scarlatinous poison 
may affect the kidneys, producing nephritis, while there is no other manifestation 
of its influence. Thus in my practice a lady of about forty-five years constantly 
attended her son, sleeping by his side, during an attack of scarlet fever. Her health 
had previously been good. When the boy was convalescent, as her appetite failed 
and she was indisposed, a careful examination revealed the fact that she had albu- 
minuria, although she had had no sore throat or other symptoms of scarlet fever. 
After several weeks of treatment her disease was removed, and she has remained 
well since. In the British Med. Jour, for Nov. 29, 1879, it is stated that in a family 
four girls were found to be suffering from desquamative nephritis. One of them 
had recently had scarlet fever, but the other three had presented no symptoms 
whatever of this disease. Such cases, although probably rare, appear to show that, 
as the scarlatinous poison may produce inflammation of the fauces without the 
occurrence of scarlet fever, so it may cause nephritis without producing the general 
disease, or apparently disturbing the functions or changing the state of other parts, 
except the kidneys. 

Symptoms. — Ordinary Form. — Scarlet fever usually begins abruptly so 
that the exact time of its commencement can be fixed. If any premonitory 
symptoms occur, they are slight, so as scarcely to attract attention, as languor 
or the appearance of fatigue. A dusky aspect of the surface may occasion- 
ally be observed during the few hours preceding the attack. In some children 
the first symptom is chilliness, and occasionally a distinct chill occurs. In 
the adult a chill is ordinarily the first symptom. With or without the initial 
chilliness fever occurs, of variable intensity according to the severity of the 
type, and accompanied by such symptoms as usually arise in a febrile state 
of system, as cephalalgia, anorexia, and thirst. The pulse rises to 110, 120, 
or more per minute, the temperature to 102°, 103°, or 104° ; the skin is hot, 
face flushed, and the eyes bright. Even in cases that are not malignant or 
grave, and that give indications of a favorable result, there is often more or 
less stupor, with transient delirium and sudden starting or twitching of the 
extremities, showing that the cerebro-spinal axis is involved. 

Vomiting is a common symptom in the beginning of scarlet fever, occur- 
ring before the appearance of the efflorescence. It therefore has diagnostic 
value when the nature of the case is still doubtful. In some patients it is an 
initial symptom, but in others some hours have elapsed when it occurs. I 
recorded its presence or absence in 214 patients, with the following result : 
present in 162 patients, absent in 52. In severe forms of the disease it is 
rarely absent, and if it do not occur it is probable that the case will be mild, 
requiring little treatment and having a favorable termination. In epidemics 
of unusual mildness the number of cases without vomiting may be in excess 
of those in which this symptom occurs. It appears to be due to functional 
disturbance of the cerebro-spinal system, and may therefore be properly 



SCARLET FEVER. 261 

regarded as a nervous symptom. In severe cases the vomiting is usually 
repeated, not only on the first but on subsequent days, and we shall see that 
in eases of great gravity, in which a fatal termination is not improbable, per- 
sistent vomiting, by which the food and stimulants so urgently required are 
rejected, interferes seriously with successful treatment. In a few cases 
embraced in my statistics nausea without vomiting was recorded. The bowels 
in ordinary scarlatina act regularly or are slightly constipated. Diarrhoea, 
which so commonly accompanies the persistent vomiting in malignant cases, 
if it occur in this form of the malady is slight and transient and due to acci- 
dental causes. The food, if it be given in the liquid form and cool, is usually 
taken readily on account of the thirst, except when deglutition is rendered 
painful by the pharyngitis. 

The symptoms pertaining to the nervous system vary according to the 
severity of the disease and the temperament of the patient. Many children 
during the progress of the common form of scarlet fever present a dull or 
apathetic appearance. They lie much of the time with their eyes closed ; 
others are more restless, and not a few, if the fever be considerable, have 
occasional twitchings of the limbs and more or less headache. Eclampsia 
sometimes occurs on the first day, especially in those predisposed to it, even 
when the subsequent course of the disease is mild and favorable. This com- 
plication, very grave and usually fatal when it occurs at a later stage, is in 
most instances, when it takes place on the first day, readily controlled by 
proper remedies and with little detriment to the patient. But if it be attended 
by high elevation of temperature and marked drowsiness, approaching the 
comatose state, it is very serious upon the first as well as upon the subse- 
quent days. Nervous symptoms occurring in the beginning of scarlet fever, 
when it has the ordinary favorable type, begin to abate in three or four days, 
but if they supervene at a later date, and especially in the declining stage, 
they possess more gravity, since they then not infrequently result from and 
indicate renal complication. 

Early in the disease, nearly as soon as the commencement of the fever, 
the faucial and buccal surfaces become inflamed, as shown by redness, swell- 
ing, and tenderness. The physician summoned in the beginning of an attack 
will already, at his first visit, observe hyperemia of the fauces, with points 
of deeper injection than over the general faucial surface, and soon the buccal 
surface also participates. The inflammation at first produces preternatural 
dryness, and this is followed by a viscid secretion. The papillae of the tongue 
enlarge and become prominent, giving rise to the appearance known as straw- 
berry tongue, which is so common in scarlet fever. This state of the buccal 
and faucial membrane continues throughout the disease. A thin fur appears 
upon the tongue on the first day, and it increases on the second and third 
days, after which it is usually detached, exposing the surface of the organ, 
which has a deep-red hue, but in not a few patients the fur remains or is 
reproduced as soon as shed. Except in the mildest cases the Schneiderian 
membrane also participates in the inflammation as the disease advances, so 
that a thin, irritating discharge containing leucocytes or pus-cells flows from 
the nostrils. The skin is hot and dry and cutaneous transpiration is nearly 
checked. The respiratory system is rarely involved in any notable manner 
unless there be a complication. Many have no cough whatever, while others 
have a slight cough, due to the fact that the catarrhal inflammation has 
extended from the fauces to the surface of the glottis. Slight acceleration 
of respiration, corresponding with the degree of fever, may also be observed. 
The kidneys commonly act regularly and normally during the first da vs. any 
serious' impairment of their functions being rare before the close of the first 
week. 



262 CONSTITUTIONAL DISEASES. 

When the symptoms described above have continued from six to eighteen 
hours the efflorescence appears. It is first observed about the ears, neck, and 
shoulders in reddish patches fading into the normal hue. These patches extend 
and unite, and in the course of a few hours the trunk and upper extremities, 
and finally the legs, are covered. The scarlatinous rash usually, when fully 
developed, resembles that produced by external heat or the application of a 
sinapism. It has been likened to the appearance of a boiled lobster, but there 
are numerous minute points of a deeper or duskier hue than the surface 
generally. In many patients the rash appears, especially over the abdomen 
and lower extremities, as minute, thickly-set points, with the skin of normal 
appearance between them. Henoch of Berlin says of scarlet fever : " In 
general, the moderate grades of eruption prevail, the skin, when seen from 
a distance, presenting a diffuse, more or less scarlet redness, while on closer 
inspection it is found that this redness is composed of innumerable red points 
closely situated together, and separated from one another by very small paler 
portions of skin. The dark -red points appear to correspond to the hair- 
follicles." On passing the finger over the efflorescence no distinct promi- 
nences are observed, but a sensation of roughness is sometimes imparted 
from engorgement of the cutaneous papillae. The rash disappears on pres- 
sure, but it immediately reappears when the pressure is removed. Its slow 
return is evidence of sluggish circulation, and it indicates a grave and dan- 
gerous form of the malady. The color is then usually a dusky instead of a 
bright red. The efflorescence is most marked in dependent parts, as along 
the back, over the chest and abdomen, and in the flexures of the joints. 
Parts pressed upon by the bedclothes, which confine and intensify the heat, 
present a deeper coloration than other portions of the surface. Often, espe- 
cially in mild cases, the rash is absent from portions of the surface where it 
commonly appears, while it presents its typical character elsewhere. Tardy 
and incomplete establishment of the rash when the symptoms indicate an 
attack of ordinary or more than ordinary severity is commonly due to some 
perturbating cause, especially diarrhoea. In the London Lancet for Aug. 16, 
1879, cases are related of supposed scarlet fever without the rash — cases in 
which pharyngitis and stomatitis with the strawberry tongue occurred, with- 
out efflorescence upon the skin ; but it is to be remembered, as stated above, 
that the inflammations which commonly attend or follow scarlet fever, par- 
ticularly the pharyngitis and nephritis, not infrequently occur in those who 
have already had scarlatina, and occur more than once from fresh exposure 
to scarlatina patients. These inflammations, occurring under such circum- 
stances, appear to be purely local maladies, produced by the scarlatinous 
virus ; and it seems to me a question whether, in the so-called scarlatina 
without efflorescence, the inflammations which are present, and which undoubt- 
edly have a scarlatinous origin, are not local in their nature, instead of being 
local manifestations of the constitutional disease. The burning and itching 
sensation produced by the rash increases the restlessness of the patient, and 
is sometimes the most annoying of the symptoms. 

The temperature in the common favorable forms of scarlet fever usually 
varies from 101° in the mildest cases to 103° or 104° in those more severe. 
If it attain 105° or over, the case is properly designated grave or severe. 
The febrile movement ordinarily fluctuates but little from day to day till the 
fourth or fifth day, when, if the case be favorable and no complication occur, 
it begins to decline. The temperature is as high in the beginning of the attack 
as subsequently. 

The symptoms pertaining to the digestive system during the initial period 
of scarlet fever have been sufficiently described. The subsequent symptoms 
referable to this system do not differ materially from those present in the 



SCARLET FEVER. 263 

beginning, except the absence of vomiting. The lips are dry and often 
cracked. The inflammation of the mouth and throat continues, with anorexia 
and thirst. With the decline of the disease the appetite gradually returns, 
but it is not till the close of the second week that it is fully restored. Great 
and continued disturbance of the digestive apparatus, seriously interfering 
with the nutrition, pertains to the malignant forms of scarlet fever. 

The urine is high-colored, and in robust children during the first days of 
scarlet fever it frequently deposits urates on cooling. Gee, who has carefully 
investigated the state of the urine in scarlet fever, says that the quantity 
of water is diminished and the urea is not necessarily increased during the 
pyrexia ; that the chloride of sodium is diminished till the fourth, fifth, or 
sixth day ; and that the phosphoric acid is diminished during the climax of 
the pyrexia, though not in the first three or four days. In one case he made a 
daily estimation of the amount of uric acid, and found it greatly diminished 
on the second and third days, normal on the fourth, and much increased on 
the fifth. He believes that similar variations are common in the quantity 
of the products excreted in the urine. Bile may also appear in the urine, 
coincident with a yellow tinge of the conjunctiva. 1 

The duration of scarlet fever varies in different cases. If the attack be 
very mild, with little efflorescence, the febrile movement may decline by the 
fourth or fifth day ; but if the disease be severe, little or no amelioration 
of symptoms may occur before the twelfth or fourteenth day, even when no 
complication has occurred to increase the temperature or cause aggravation 
of symptoms. Octerlony, who estimated the duration of scarlet fever from 
the commencement of febrile symptoms to " the disappearance of fever, with 
marked improvement in leading symptoms," . . . . " found that the average 
duration of the disease in forty cases was six and one-sixth days. The 
minimum duration in a very slightly marked case was three days : the maxi- 
mum duration was fourteen days." In general, prolongation of fever beyond 
the usual time is due to some complication — more frequently to unusually 
severe pharyngitis, with accompanying cellulitis, than to any other cause. 

The malady whose commencement was so abrupt declines gradually. In 
ordinary cases, by the close of the first week or in the beginning of the 
second the rash becomes less and less distinct, and finally disappears, as do 
also the redness and swelling of the buccal and faucial surfaces. The engorge- 
ment of the tonsils and of the papillae of the tongue subsides, the appetite 
returns, the countenance brightens and becomes natural, and the child, who 
during the height of the fever scarcely noticed objects or noticed them with 
indifference or even repugnance, can be amused as before his sickness. 

Desquamation succeeds. This begins at about the sixth day, and is not 
completed till the tenth or twelfth day, often not till the close of the third 
or in the fourth week. The amount of desquamation corresponds with the 
intensity and duration of the efflorescence, or rather of the dermatitis which 
produces the efflorescence. If the efflorescence have been slight and partial, 
it will be slight, perhaps scarcely appreciable, but if the rash have been 
general, full, and protracted, exfoliation occurs upon every part. It begins 
about the face and neck, and within a day or two appears upon other parts. 
Where the skin is thin the epidermis as it is detached presents a furfuraceous 
appearance ; where it is thick, as upon the palms of the hands or soles o'l the 
feet, it separates in layers of considerable thickness. 

Such is a brief description of scarlet fever when it pursues its normal 
course without any disturbing element, but there is no other disease in which 
complications and sequelae so frequently occur. The liability to them renders 

1 Article on Scarlatina in Kevnolcls's System of Medicine. 



264 CONSTITUTIONAL DISEASES. 

the prognosis in every case doubtful. They largely increase the percentage 
of deaths. They occur both in mild and severe forms of scarlatina.. 

The difference in type in different cases and epidemics has already been 
alluded to. Scarlet fever is sometimes so mild and its symptoms so slight that 
the diagnosis is necessarily uncertain. In the spring of 1866, I was called 
to an infant thirteen months old who had slight pharyngitis and an indistinct 
rash over a part of the surface. In two days the eruption had disappeared, 
and the health within a day or two was apparently fully restored. Diagnosis 
would have been doubtful except for sequelae which clearly indicated the 
scarlatinous nature of the attack. In another instance two children passed 
through the entire course of scarlet fever, playing every day in the street. 
Although the intelligent grandmother saw the rash upom them, its nature was 
not suspected, as it was midsummer and cases of prickly heat common, till 
nearly two weeks afterward, when one of the children had nephritis and 
anasarca, ending fatally. In cases so mild as these the heat of the surface 
is but slightly increased, the pulse but little accelerated, and the rash usually 
does not occupy so much of the surface as in ordinary cases ; the appetite is 
not lost, though diminished, and the thirst is moderate. 

Between scarlet fever so mild that it terminates in four or five days, and 
that of the grave or malignant type presently to be described, all grades of 
severity exist. Scarlet fever occurs in all forms from mild to severe, but 
certain symptoms characterize grave or malignant cases — symptoms which 
are absent or much less prominent in ordinary scarlet fever. Therefore the 
grouping of cases according to the type is proper, and it facilitates the study- 
ing of the disease. 

Grave Form (malignant scarlet fever). — This form of the disease is in 
some epidemics common, while in others it is rare. The symptoms which 
characterize it are severe from the beginning, those of the nervous system 
predominating at first, such as intense cephalalgia, restlessness or stupor, 
sudden twitching of the muscles, and perhaps delirium or even convulsions. 
Many pass rapidly into coma and die within two or three days, succumbing 
to the intensity of the scarlatinous poison while the malady is still in its 
commencement. The rash is dusky. It disappears by pressure, and returns 
slowly when the pressure is removed, showing extreme sluggishness of the 
capillary circulation. Some patients are very drowsy, lying in a semi-comatose 
state except when aroused, and if aroused are very restless. Others are con- 
stantly restless. If placed in one position on the bed, they throw themselves 
in another in a half-conscious or unconscious state. They do not speak, or 
they mutter like those affected by the graver forms of typhus, calling the 
names of playmates or talking incoherently about things which interested 
them when well. The thermometer placed in the axilla is found to rise above 
103°, which is a safe average, to 105° or even 107°, and the heat of the sur- 
face is pungent except when the case approaches a fatal termination, when 
the extremities, ears, and nose may be cool while the trunk and head are 
extremely hot. The pulse from the first is rapid, ranging from 130 as the 
minimum in a malignant case to a frequency which can scarcely be counted. 
A very frequent pulse is nearly always feeble and compressible. Irritability 
of the stomach is- one of the most common symptoms in grave cases, so that 
many patients immediately reject the nutriment and stimulants which are so 
urgently required to sustain the vital powers. The vomiting, therefore, if 
frequent and severe, greatly increases the danger, and in not a few instances 
this symptom is associated with diarrhoea, which also tends to increase the 
prostration. 

Severe and dangerous nervous symptoms, due to the intensity or activity 



SCARLET FEVER. 265 

of the scarlatinous poison, occur chiefly within the first three or four days. 
Grinding the teeth, sudden muscular twitching, delirium, convulsions, and 
profound stupor occur for the most part within this time. Afterward the 
danger is mainly from exhaustion, unless in the second week or subsequently, 
when nervous symptoms may arise from uraemia. 

Those who survive the onset of malignant scarlet fever often have in the 
course of a few days severe pharyngitis, with extension of the inflammation 
to the lymphatic glands and connective tissue around the angle of the jaw. 
These inflammations cause more or less external swelling. The faucial tur- 
gescence around the entrance of the larynx, with the accompanying secretions 
of viscid mucus or muco-pus, often causes noisy respiration, and many at this 
stage of the attack breathe with the mouth constantly open to facilitate the 
ingress of air. 

Ordinarily, no discharge occurs at first from the nasal surface, but as the 
disease continues, if the type remain severe, deflexion of thin muco-pus takes 
place from the Schneiderian surface, which excoriates the cheek. The lips 
also are frequently sore and swollen. 

In malignant cases the disease is more protracted than when the type is 
mild. Thus in a recent case in my practice the rash was still distinct at the 
close of the second week, though the temperature had fallen from 105° to 
102°, and some desquamation had appeared. Long continuance of the febrile 
movement is, however, oftener attributable to some inflammatory complica- 
tion than to the primary disease. 

In all epidemics of a severe type, cases now and then occur in which the 
poison is so intense, or it acts with such frightful energy, that death occurs 
even within the first day. The patient is overpowered at the outset of the 
disease by the virulence of the specific principle, perishing in coma, preceded 
perhaps by convulsions. The autopsy in such cases reveals hyperemia of 
the brain and cranial sinuses, blood of a dark -red color, capillary hemorrhages 
in various parts, a flabby heart, and perhaps some engorgement of the spleen 
and kidneys. 

Usually, malignant scarlet fever exhibits its severe type from the first, but 
cases sometimes occur which seem mild and favorable for a few days, when 
severe symptoms suddenly supervene. This change from a mild to a danger- 
ous disease is, however, most frequently, I think, due to some complication. 

Irregular Forms. — Deviation from the normal type in scarlet fever is usually due 
to some perturbating cause, which is often a pre-existing or coexisting disease or a 
disordered state of system through causes distinct from scarlatina. Thus, a little 
girl in my practice had the symptoms of scarlet fever, such as febrile movement 
and inflammation of the buccal and faucial surfaces, nearly a week before the scar- 
latinous eruption appeared. During this time the patient had an intestinal catarrh, 
with diarrhoea, which declined when the rash occurred. This intestinal disease was 
the apparent cause of the irregularity in the malady. If scarlatina occur during a 
severe attack of entero-colitis attended by purging, the defluxion from the intestinal 
surface may be such that no efflorescence appears. Severe scarlet fever itself some- 
times appears to cause gastro-intestinal catarrh, so as to produce an afflux of blood 
toward the intestinal tract and away from the skin. Practitioners occasionally moor 
cases like the following, which I recall to mind : In a family where scarlatina was 
prevailing a little child early after the commencement of the symptoms which 
seemed to be plainly referable to this exanthem was seized with vomiting and 
purging, which continued till death occurred on the third day. ^ No efflorescence 
appeared on the skin, but the symptoms indicated the presence o'l severe intestinal 
catarrh, complicating and masking scarlatina. We are aided in the diagnosis o\' such 
cases by observing the faucial redness, and we may discover a faint efflorescence 
upon parts of the'surface, as about the groin or in the flexures of the joints. In 
another instance an infant in the warm months, having protracted entero-colitis, 
the usual summer epidemic of the cities, had the characteristic symptoms of scarlet 



26Q CONSTITUTIONAL DISEASES. 

fever, which was present in the family, but the diarrhoea continued and no rash 
appeared. 

In one who is much reduced by an antecedent disease, especially if, like the 
intestinal catarrh mentioned above, it produces a decided afflux of blood away from 
the surface and toward the interior of the body, the eruption is commonly tardy in 
its appearance, indistinct, or wholly absent. On the other hand, some maladies 
occurring in connection with this exanthem do not change its symptoms, but them- 
selves undergo modification. Pertussis may be cited as an example, the cough of 
which is sometimes modified by an intercurrent attack of scarlet fever, the symp- 
toms of the latter disease undergoing little change. 

Scarlet fever may also be irregular without any apparent perturbating cause. 
In 1867, I attended a young lady whose previous health had been good, and whose 
brother was sick at the time with scarlet fever. She had marked elevation of tem- 
perature, with severe pharyngitis, and, though her surface was repeatedly examined, 
no efflorescence was seen. Two weeks subsequently she was aifected with severe 
nephritis, anasarca, effusion into at least one of the pleural cavities, oedema of the 
lungs, and, according to my diagnosis, hydro-pericardium, the case ending fatally. 
Rilliet and Barthez state that a second attack of scarlet fever is more likely to be 
irregular than the first. Probably this opinion is correct, especially if only a short 
time have elapsed between the two seizures. Still, as we have already stated, both 
seizures may be typical, and the second more severe than the first. 

It would be impossible to make a clear and positive diagnosis of certain cases 
of irregular scarlet fever, in which cerebral, pulmonary, or gastro-intestinal symp- 
toms predominate, were it not for the fact that they occur in connection with other 
cases of scarlet fever or are followed by sequelae which evidently have a scarlatinous 
origin. 

Occasionally, the eruption, if it be intense or if a certain condition of system 
be present in the patient, is accompanied by more or less extravasation of blood- 
corpuscles from the capillaries, usually in points, so that the redness does not entirely 
disappear on pressure. In rare instances certain of the exanthematic fevers present 
an extreme hemorrhagic character, so as to be beyond the reach of remedies and 
of necessity speedily fatal. Hemorrhagic cases of this severe form are probably 
more common in variola than in the other fevers, but I have met a notable case in 
what was diagnosticated scarlatina, in June, 1881, a man in his thirty-second year, 
whose previous health had not been good, though he had no defined ailment and 
had been able to follow his occupation of harness-maker, suddenly became very ill, 
with great elevation of temperature and faucial inflammation, attended by marked 
prostration. After some hours an intense eruption of a scarlatinous appearanee 
covered nearly the entire surface, and on the following day hemorrhages began to 
occur. The urine contained a large proportion of blood ; each conjunctiva was 
raised by hemorrhages underneath (ecchymosis), so that its natural color was lost, 
the eyelids were closed with difficulty, and blood flowed from the nostrils, gums, 
and under the skin, forming hemorrhagic points and blotches. One of the consult- 
ing physicians, perceiving the resemblance to hemorrhagic variola as described by 
Hebra, suspected that we had a case of this formidable malady to deal with, but 
the time for the appearance of the variolous eruption passed by without its occur- 
rence. Death took place on the fifth day. The temperature during the sickness 
remained high, though the record of it has been mislaid. Fortunately, such severe 
hemorrhagic cases, which are necessarily fatal, are rare. 

Complications and Sequels. — Scarlet fever, if its type be severe, is in 
itself dangerous to life. Many, as we have seen, perish from its direct effects 
when it produces profound blood-poisoning. But while the ordinary epi- 
demics of this malady are necessarily attended by a large mortality from the 
virulence and depressing effect of the specific principle, unfortunately, of all 
the diseases of modern times, scarlatina ranks first as regards the number and 
gravity of its complications and sequelae, so that nearly or quite as many 
perish from these as from the direct effects of the poison. 

Nervous accidents occur chiefly at two periods — to wit, in the first days, when 
they are due to the severity and malignity of the malady and to the impressible 
nervous temperament of the child ; and in the declining stage or after the termi- 



SCARLET FEVER. 267 

nation of the fever, when they occur from uraemia. If the type be malignant, 
delirium, jactitation, profound stupor, and convulsions frequently occur on the first 
and second days : and these are symptoms which properly excite the most alarm 
and demand all the resources of our art, since they indicate a form of the disease 
which frequently ends in speedy death. The eyes have a dull or wild expression, 
the conjunctiva is suffused, the heat of surface pungent, the pulse rapid and com- 
pressible or feeble, rising above 150, even to 200, per minute, and the temperature 
is always elevated to a degree that involves danger, the thermometer not infre- 
quently indicating 105° or 106°. But this severe form of scarlet fever, attended by 
so great elevation of temperature, is much less dangerous than in former times, 
even though it be complicated by delirium and convulsions, since we no longer 
hesitate to reduce bodily heat, when excessive, by the free use of cold baths, and 
have discovered potent agents in the bromides and chloral for controlling convul- 
sions. Nevertheless, not a few perish in the commencement of scarlet fever with 
predominating cerebral symptoms, as delirium or eclampsia, followed by coma, 
under the best possible treatment. Sometimes the symptoms have closely simu- 
lated those of acute meningitis, and if the rash have been delayed and the sore 
throat is as yet slight, the physician may suspect that he is dealing with this 
disease ; but autopsies in such cases show no inflammatory lesions, but only con- 
gestion of the cerebral and meningeal vessels. 

As is stated in a preceding page, in every case of normal scarlet fever inflam- 
mation of the faucial surface is present, as indicated by redness, tenderness, and 
increased secretion of mucus or muco-pus. It precedes the efflorescence on the 
skin, and is announced by pain in swallowing and on pressure with the fingers 
behind and below the angles of the jaw. In that form of scarlet fever which has 
been designated anginose the pharyngitis is severe, and is a prominent element in 
the malady, the uvula, the pillars of the fauces, and the faucial surface in general 
being infiltrated and swollen. Nevertheless, this inflammation, with the accom- 
panying tumefaction, is properly a part of the disease, rather than a complication, 
if it abate with the subsidence of the scarlet fever or begin to abate soon after, 
and if it produce but slight destructive change in the tissue of the neck. The 
secretions from the fauces may be foul and offensive ; even superficial ulcerations 
or gangrene may occur upon the faucial surface, causing it to present a dark-brown 
or jagged appearance, and the tissues of the neck may be infiltrated to a certain 
extent, and we designate the disease a form of scarlet fever under the title anginose. 
But when this condition is greatly aggravated, so that extensive infiltration and 
swelling of the tissues of the neck occur, with an amount of ulceration or gan- 
grene which in itself involves danger, continuing after the primary disease abates, 
prolonging the fever and reducing the strength, it is proper to regard the state 
of the throat as a complication. In addition to the pharyngitis, which is severe, 
as described above, the sides of the neck around the angles of the jaw become 
swollen, hard, and tender. The inflammation has been propagated to the deeper 
structures of the neck. Poisonous substances, the result of decomposition or vitiated 
secretions, traverse the lymphatic vessels from the faucial surface, and being inter- 
cepted in the lymphatic glands, cause adenitis, and the inflammation extends from 
the glands to the adjacent connective tissue, which becomes hard, tender, swollen, 
and infiltrated with inflammatory products. This tumefaction sometimes begins 
by the second or thiru day, but it is usually about the close of the first week or 
in the beginning of the second week that it becomes so considerable as to consti- 
tute a source of danger and anxiety. It is in most cases bilateral, though one side 
.may begin to swell before the other and remain larger throughout. 

In severe cases of this complication the tumefaction extends from ear to ear. filling 
up the space below and around the angles of the jaw and under the chin. Not only is 
deglutition difficult, but it is difficult to open the mouth sufficiently to inspect the 
fauces, and attempts to do so cause much pain. The lymphatic glands, which lie in the 
inflamed area and participate in the inflammation, are greatly enlarged by hyper- 
plasia, the round granular lymph-cells multiplying so abundantly that the glands 
increase to many times their normal size. Most of the tumefaction is, however, due 
to extension of the inflammation to the connective tissue of the neck. The cellu- 
litis, which resembles that occurring in other conditions, is attended by distention 
of the capillaries, the abundant formation of young round colls, and transudation 
of serum (Billroth). A moderate amount of tumefaction may disappear by resolu- 
tion, but if it be considerable it seldom abates in this way, but by the tedious and 



268 CONSTITUTIONAL DISEASES. 

exhausting process of suppuration or gangrene. If the swelling at its most prom- 
inent point presents a reddish hue, all hope of producing resolution must be aban- 
doned ; it cannot be effected by any medicine or appliance within the resources of 
our art. The abscess which forms is likely to be diffuse, so as to involve danger of 
pyaemia, unless it be soon opened and properly washed out. With the discharge 
of the pus the swelling gradually softens and declines. In other cases gangrene 
results. The vessels in the inflamed part are compressed by the inflammatory prod- 
ucts, so that they no longer convey the blood which is required for the purpose of 
nutrition. It is a law of the system that whenever the circulation ceases the 
tissues which receive their nutritive supply through the obstructed vessels lose their 
vitality. Hence gangrene occurs in all that portion of the swelling in which the 
circulation is arrested. The skin over it peels off, the dead tissue underneath is 
brown or dark, and soon, if life be prolonged, the slough begins to separate. The 
prognosis as regards this complication depends largely on the size of the slough. 
If it be large, death will probably result, since the strength of the system is already 
reduced by the primary disease, and the reparative process will necessarily be slow, 
while abundant suppuration tends to increase the exhaustion. In some of the 
worst cases of cervical gangrene which I have seen the slough has laid bare the 
muscles and vessels of the neck, producing in one case a cavity or excavation suffi- 
ciently large to admit a hen's egg. Often the slough extends under the skin, so that 
the deepest recesses of the cavity are not visible, and occasionally, in cases which 
have ended fatally in my practice, severe hemorrhage occurred from the concealed 
vessels. If the ulcerative or gangrenous process extends so deeply into the tissues 
of the neck that hemorrhages occur, death is the common result: but if the destruc- 
tive action be of moderate extent and other conditions favorable, we may expect 
recovery through cicatrization, with perhaps some deformity by contraction of the 
cicatrix. 

When the inflammation of the connective tissue of the neck is extensive, in- 
volving both the lateral and anterior regions of the neck, the patient is in a perilous 
state. The cellulitis, when extensive and accompanied by much swelling, may pro- 
duce oedema of the glottis, may obstruct respiration by compressing the air-passages 
or the laryngeal nerves, may cause compression of the jugular veins, and thus give 
rise to dangerous cerebral symptoms, or may lay bare and injure important muscles 
and nerves, as we have seen. If the ulceration or gangrene be extensive, and death 
do not occur by hemorrhage from arterial or venous twigs, septic poisoning may 
occur, increasing still more the fatal nature of the malady. 

Some cases of this complication are melancholy in the extreme, as one related 
by Cremen, in which ulceration of the pharynx occurred, allowing the escape of 
food and preventing deglutition. In severe scarlatinous pharyngitis the inflamma- 
tion sometimes extends along the Eustachian tube, causing its occlusion. This acci- 
dent will be considered when we treat of otitis media, another grave complication. 
It often also extends into the nares, causing catarrh of the Schneiderian mucous 
membrane, with discharge of muco-pus from the surface. Not infrequently ulcera- 
tion or gangrene occurs in the faucial surface, producing more or less destruction 
of tissue and forming excavations, while the cutaneous surface retains its integrity 
and is not even reddened. The following case shows how grave the complication 
which we are now considering sometimes is when the external surface of the neck 
is not involved, and how the inflammation by extension outward from the fauces 
may involve the middle ear : 

Case 1. — Annie K , aged two and a half years, an inmate of the New York 

Foundling Asylum, was well, except an eczema of the scalp, until the night of April 
3, 1882, when she was attacked with vomiting and diarrhoea. She was feverish and 
drowsy, and at 2 p. m, on the 4th the scarlatinous efflorescence appeared upon her 
neck, body, and lower extremities ; tongue coated ; pharynx red : temperature 
(axillary) 103°; pulse 160. The symptoms and aspect indicated a grave form of 
the malady, and the usual sustaining treatment was ordered. On April 5th the 
temperature was 102°, pulse 144, tongue less coated, eruption fading, less stupor, 
no albumen in urine. April 6th, morning temperature 102°, pulse 160; passed a 
restless night : stools thin and too frequent ; has grayish patches in the throat ; p. m. 
temperature 103.2°, pulse 150. April 7th, the diarrhoea continues, and she has a 
copious muco-purulent discharge from the nostrils : p. m. temperature 103.6°, pulse 
160. April 10th, the temperature has continued at about 103° ; the patient is very 
sick, with a constant foul-smelling discharge from the nostrils ; breath very offen- 



SCARLET FEVER. 269 

sive : temperature 103.5°, pulse about 180. April 12th, general appearance a little 
better, but the posterior surface of the fauces is completely covered by a thick pseudo- 
membrane ; had four loose stools last night ; temperature and pulse the same as at 
last record ; a dark, offensive, and jagged coating over the fauces, and a dark, foul 
discharge from the nostrils as before : examination of the chest negative. April 
14th. is much prostrated ; temperature 104.5°, pulse rapid and weak ; respiration 
noisy : diminished resonance over lower two-thirds of left side of chest ; ulcers 
upon the mouth and tongue ; fauces red and ulcerated. April 17th, pulse 150, tem- 
perature 100.5°; general appearance somewhat better, but the diarrhoea continues, 
and patches of a diphtheritic character have appeared upon the lips ; moist rales 
in left side of chest. The symptoms continued nearly the same until April 23d, 
when she died. A dull percussion sound and distinct bronchial respiration were 
observed in the left scapular region during the last days of her life. 

Autopsy nine hours after death by the curator : Body well nourished ; the tis- 
sues have a jaundiced hue ; lips sore ; on turning the head to one side pus runs 
from the left ear and dirty muco-pus from the mouth. Brain normal ; on opening 
the petrous portion of the left temporal bone the middle ear is found full of pus, 
which communicated freely with the external ear through a perforated membrana 
tympani : the Eustachian tube cannot be traced in the sloughy tissue, and a passage 
filled with pus extends from the ear to the fauces ; opposite the greater cornua of 
the hyoid bone are two deep ulcers, each having about the diameter of a ten-cent 
piece, with sloughy and offensive base and sides ; the left ulcer communicates by 
a, ragged and wide sinus with a dark and sloughy cavity of about four drachms 
capacity, this cavity is located in the neck under the angle of the jaw, apparently 
occupying the site of a disintegrated gland, and it opens upon the surface of the 
fauces. The surface of the larynx has a dusky, dirty appearance, sprinkled with 
little cheesy-looking spots, and covered by a dirty, foul-appearing liquid, as if some 
of the ichorous pus had escaped into it from the neck ; about one and a half inches 
below the vocal cords there is an unmistakable pseudo-membrane ; below this, near 
the bifurcation, the trachea has a bright-red color, as if a pseudo-membrane had 
been peeled from it, leaving the surface raw. The detachment of a pseudo-mem- 
brane from this part, if it did occur, must have been ante-mortem, for the organ 
had been carefully handled in making the autopsy. Between the apex of the left 
lung and the median line the tissues of the neck, dissected upward, are found 
indurated, yellow, and giving an offensive odor, showing that the cervical cellulitis 
had extended downward farther than usual. The bronchial glands have undergone 
hyperplasia, being enlarged and hard. The right lung is normal : about one-half 
of the left lower lobe is consolidated, and when cut is found to be gangrenous and 
offensive. The liver is apparently somewhat enlarged ; spleen normal in size ; 
gastric mucous membrane has a congested appearance and is covered with mucus ; 
mesenteric glands enlarged, pale, and firm ; Peyer's patches swollen and pale ; at 
lower end of ileum some pigmentation of these glands ; in large intestine the 
solitary glands are enlarged, and a few of them pigmented ; kidneys pale, cortex 
thickened, and markings indistinct. Microscopical examination : In the pia mater 
perhaps a little increase of cells ; meninges of brain otherwise normal. The trachea 
shows well-marked diphtheritic inflammation ; it contains a film of pseudo-membrane ; 
evidences of inflammation occur also upon the laryngeal surface, though less marked 
than in the trachea. The solidified portion of the lung exhibits the ordinary lesions 
of broncho-pneumonia, with some interstitial change. In the kidneys we find paren- 
chymatous nephritis, with some cell-growth in the Malpighian bodies. 

The above case has been related at length, not only because it shows how 
severe and destructive the inflammation of the throat, extending into the 
tissues of the neck, sometimes is, but because four other complications or 
sequelae were also present — to wit, otitis media, diphtheria, nephritis, and 
pneumonia. We see how formidable a disease scarlet fever sometimes is 
when attended by the inflammations to which it so frequently gives rise, for 
a child older and stronger than this, if thus affected, would inevitably have 
perished with the best possible treatment. 

In localities where diphtheria is endemic, as in New York City and Paris, 
scarlet fever is often complicated by pseudo-membranous inflammations of the 
fauces and air-passages. In severe cases the Schneiderian as well as the 



270 CONSTITUTIONAL DISEASES. 

faucial surface is covered with pseudo-membrane, so that it can be readily 
seen on inspecting the anterior nares. Occasionally, this exudation appears 
upon the laryngeal and tracheal surfaces, as in the case which I have related 
above and in others presently to be related, causing dangerous embarrassment 
of respiration. This complication sometimes begins almost at the commence- 
ment of scarlet fever, but in most instances it does not occur before the third 
or fourth day, and it sometimes does not appear till in the declining stage of 
the fever. When it begins it intensifies the fever and produces general 
aggravation of symptoms. 

The elaborate treatise by Sanne of Paris on diphtheria contains a chapter 
entitled " Secondary Diphtheria." In it the author says, what all who are 
familiar with diphtheria will agree to, that secondary diphtheria does not 
differ in nature from the primary form, and that it exhibits a tendency "to 
occupy the organs which are themselves the seat of the more pronounced 

local determinations of the primitive malady Diphtheria is seen in 

the course or sequel of numerous diseases. Some appear to have a special 
proclivity for engendering diphtheria ; these are specific maladies : measles, 
scarlet fever, pertussis." Sanne's statistics relating to the seat of scarlatinous 
diphtheritic exudation are as follows : 

Fauces alone attacked 15 cases. 

Fauces with larynx attacked 4 

Fauces with nasal fossa attacked 8 

Fauces with larynx and nasal fossa attacked 4 

Fauces with larynx and bronchi attacked 1 

Fauces with nasal fossa and lips attacked . 1 

Fauces with lips and skin attacked 1 

Fauces unaffected 3 

Diphtheria generalized 2 

Larynx only affected 2 

Nasal fossa 1 

The pellicular exudate upon the laryngotracheal surface is treated else- 
where in this book. 

Coryza frequently commences at or about the time of the pharyngitis. 
The inflammation of the Schneiderian membrane is continuous posteriorly 
with that of the fauces, and is announced by redness and swelling, inability 
to breathe freely through the nostrils, and an irritating ichorous discharge. 
Simple coryza in itself involves little danger, though it is an unpleasant com- 
plication, and in the nursing infant it may interfere with drawing the nipple. 
Diphtheritic coryza, on the other hand, which is frequently present when 
diphtheria complicates scarlet fever, involves danger, since it is apt to cause 
ulcerations, hemorrhages, and septic poisoning. When the local symptoms 
are unusually severe and the discharge abundant, it is probable that inflam- 
mation has in some cases extended to the antrum of Highmore. 

Inflammation of the Middle Ear is another unpleasant and not infrequent 
complication. The statistics of different aurists collated by Dr. C. H. May, 
and presented in a paper on scarlatinous otitis read before the Pediatric Sec- 
tion of the New York Academy of Medicine, March 4, 1889, show that about 
5 per cent, of all aural affections result from scarlet fever, and in 10 per cent, 
of the cases of total deafness the loss of hearing is from this disease. It is 
due to extension of the catarrh from the pharynx along the Eustachian tube 
to the tympanum. In a considerable proportion of cases of otitis media this 
tube is occluded by the infiltration and swelling of its mucous membrane, so 
that the muco-pus escapes with difficulty or is retained. Hence severe ear- 
ache, an increase of the febrile movement, and outward bulging of the mem- 
brana tympani occur. Sometimes headache or other cerebral symptoms arise, 



SCARLET FEVER. 271 

probably from the fact that the meningeal artery, which supplies the meninges, 
is connected by anastomosing branches with the tympanum. In one of the 
cases related above it will be recollected that the ulceration and abscess 
extended from the fauces to the middle ear, the entire Eustachian tube 
having disappeared in the ulcerative process. 

Frequently, the otitis escapes detection, its symptoms being masked or 
obscured by the general disease, until the membrana tympani is perforated 
and otorrhoea begins ; but by careful examination the nature of the complica- 
tion can usually be ascertained before the ear is injured to this extent, for a 
patient too young to speak will often press with the fingers against the painful 
ear or lie with the ear pressed upon the pillow, evidently having an increase 
of suffering if placed in any other position. One old enough to speak and in 
proper mental condition makes known the earache as soon as it occurs. In 
most instances the scarlet fever has continued some days when the otitis 
begins. The otitis may begin insidiously, but in other instances it begins 
with a chill and a rise of temperature to 104° or 105°. The pain referred to 
the ear may be paroxysmal, and it is usually worse at night. It may radiate 
from the ear, following the branches of the fifth nerve. The patient expe- 
riences pain on pressure upon and around the tragus, and when the inflamma- 
tion extends to the mastoid cells, pressure upon the mastoid process is also 
painful. The otitis may be unilateral, but in a large proportion of cases it 
is bilateral. 

The mucous membrane of the tympanum, red and swollen from inflamma- 
tion, secretes muco-pus abundantly, and this, pent up in the cavity, must 
obtain an exit before relief occurs. It is well if the secretion escape, though 
with difficulty, down the Eustachian tube. The destructive action of the pus 
upon the delicate structure of the ear is often such that within a few days 
irreparable harm is done and more or less deafness results. Relief can occur, 
if the Eustachian tube remain closed, only by perforation of the membrane 
and the discharge of the secretions into the external meatus. When this 
takes place the inflammation in the most favorable cases gradually abates, the 
aperture in the drum closes, and the integrity of the auditory apparatus is 
preserved. In severe cases the mastoid cells participating in the inflammation 
become filled with muco-pus and tender to the touch, and often the collateral 
oedema causes tumefaction and narrowing of the external ear, which subside 
with the discharge of pus from the tympanum. 

Unfortunately, there is for many a more melancholy history — a more 
destructive inflammation, involving permanent impairment or total loss of 
hearing. This most frequently takes place in strumous or feeble children. 
All grades of inflammation and destructive action occur in different cases. 
The perforation in the drum-membrane may be large or the membrane may 
be completely destroyed, and the detached ossicles escape one by one into 
the external meatus, and in a few instances, fortunately rare, this occurs in 
both ears, producing complete and permanent deafness. In my own practice 
this has never occurred, but I have met one or two adults who were totally 
deaf from this cause. 

The mucous membrane which lines the bony wall of the middle ear has 
the function of the periosteum, and therefore when inflamed and subjected to 
pressure is liable to ulcerate. As in other parts of the skeleton under similar 
conditions, superficial caries or necrosis of the underlying bone is liable to occur. 
The carious or necrotic process may extend to the mastoid cells. An offensive 
otorrhoea, continuing for months or years, indicates the persistence o\' this 
pathological state of the tympanum, which is rendered so obstinate by the 
presence of dead bone. A moment's survey of the anatomical relations of 
the middle ear shows the danger to which these patients are liable. A thin 



272 CONSTITUTIONAL DISEASES. 

bony septum, perforated with blood-vessels, and sometimes containing con- 
genital apertures, separates the tympanum from the cranial cavity above. 
Posteriorly lie the mastoid cells, connected with the tympanum by one large 
and several small apertures. Anteriorly is the commencement of the Eus- 
tachian tube, and in close proximity to the tympanum lies the carotid canal, 
and at one point also the superior petrosal sinus. Virchow has shown how 
inflammation extending from the ear in otitis media sometimes produces such 
compression of the veins or sinuses by the swelling from the infiltration and 
exudation that the circulation is arrested, and the fibrin contained in the 
blood of these vessels is precipitated, forming thrombi, with the most disas- 
trous effect upon the individual. Pus may also burrow in the interstices of 
the bone, causing great pain, or the pent-up secretions, having no outlet for 
escape, may in time undergo caseous degeneration, producing the conditions 
in which tuberculosis so often originates. 

Death not infrequently occurs in chronic otitis media in another way. 
The otorrhcea, after months or years, suddenly ceases, the child complains of 
constant severe headache and is feverish, and the case ends in coma, preceded 
perhaps by convulsions. Meningitis has occurred, produced by extension of 
the inflammation through the thin bony septum which divides "the tympanum 
from the cranial cavity, and at the autopsy hyperemia of the meninges, fibrin, 
pus, perhaps softening of the brain and an abscess, are found in the portion 
of the encephalon adjacent to the tympanum. Therefore, otitis media, though 
it often ends favorably, is in many patients an obstinate, dangerous, and even 
fatal sequel of scarlet fever. 

The complication known as scarlatinous rheumatism is regarded by some 
as a synovitis, but its symptoms, especially its shifting from joint to joint, 
seem to ally it to the rheumatic affections. In some epidemics it is common. 
It usually begins toward the close of the first week or in the second week, 
and its common seat is in the ankle, phalangeal, and wrist joints. It is 
attended by very little swelling in most patients, though the joints are tender 
and painful on pressure. It does not seem to retard convalescence materially, 
but it produces suffering and involves danger as regards the heart. It sub- 
sides in a few days with the ordinary treatment of acute rheumatism, and 
even without special treatment, the chief danger being that, as in idiopathic 
rheumatism, endocarditis may arise, with permanent crippling of the valves. 
The following was a case of valvular disease having this origin. It occurred 
in my practice. 

Case 4. — Freddy M , aged four years, sickened with scarlet fever March 6, 

1879. The usual vomiting occurred on the first day, and the temperature was 104°. 
The case progressed favorably till March 14th, when he complained of pain in both 
wrists, both ankles, and both knees. On March 17th the general condition was good, 
the urine contained no albumen and apparently few urates, but he still had pain in 
the joints of the upper and lower extremities and in the back ; pulse 140, tempera- 
ture 103° ; breathes with a slight moan; urates in the urine, but no albumen. A 
distinct mitral regurgitant murmur is now heard for the first time. Under the use 
of salicylate of sodium the pain in the joints soon ceased, but the mitral murmur 
is permanent. 

The following prescription is for a child of five years : 

R. 01. gaultheriae, fgj ; 

Sodii salicylat, giij ; 

Syrupi, fgij ; 

Aqua?, f^iv. — Misce. 

Sig. : Give one teaspoonful every four hours in water. 

Of the serous inflammations complicating scarlet fever, pericarditis has 
been, according to Rilliet and Barthez, most frequently observed. In this 



SCAB LET FEVER. 273 

country it is probably more common than is usually supposed, but it is less 
frequently detected than pleuritis, the symptoms of which are more con- 
spicuous. 

The following case, which occurred in my practice, was an example of this 
complication : 

Case 5. — C , girl, aged five years and ten months, sickened with severe 

scarlet fever on April 4th. Was delirious ; pulse 158 ; had vomiting and consti- 
pation. April 10th, pulse varies from 124 to 153, no delirium ; a considerable 
quantity of urates in the urine. April 11th, has to-day, for the first time, severe 
pain in the epigastrium, with tenderness and moderate distention. Otherwise 
symptoms favorable, but severe ; pulse 140 ; respiration moderately accelerated 
and vesicular in every part of the chest. From this date the symptoms continued 
about the same till April 14th, when the dyspnoea became more marked and the 
action of the heart rapid and tumultuous. The epigastric pain, distention, and 
tenderness continued : the percussion sound was dull over the lower part of the 
chest : the dyspnoea became rapidly worse, although the pulse had considerable 
volume : and at 5 p. m. death occurred. At the autopsy about one ounce of turbid 
serum, with a soft deposit of fibrin, was found in the pericardium. Each pleural 
cavity contained from six to eight ounces of transparent serum, and both lungs 
were readily inflated, except a little of the posterior portions of both lower lobes : 
no fibrinous exudation over the lungs. The liver extended four inches below the 
margin of the ribs, and upon its convex surface in the epigastrium, corresponding 
with the seat of the pain, was a rough patch of fibrin about one and a half inches 
in diameter. The bronchial mucous membrane was moderately injected, as was 
also that of the colon, and the kidneys appeared hyperaeinic. 

Among the serous inflammations which complicate or follow scarlet fever, 
pleuritis is one of the most important. It usually begins in the desquamative 
stage, and is frequently suppurative, on account of the feeble state of the 
patient when it commences. It has, in my practice, been tedious, as all 
empyemas are, and it does not differ in its clinical history from the idio- 
pathic disease. I have met cases of scarlatinous empyema in which, from 
opposition of the family, or for other reasons, thoracentesis was not per- 
formed and death occurred ; others in which this operation effected a cure ; 
and one, at least, in which the patient recovered by escape of pus through 
a bronchial tube and its expectoration. The pleuritis is seldom latent, or so 
masked by the symptoms of the general disease that it is liable to be over- 
looked. On the other hand, the cough, embarrassment of respiration, and 
pain referred to the affected side render diagnosis easy. 

Dilatation of the heart is common in grave cases of scarlet fever, such 
cases as are properly termed malignant. It is indicated by a feeble and quick 
pulse. Acute infectious maladies, especially those of a malignant type and 
accompanied by a marked rise in temperature, are very liable to cause paren- 
chymatous degenerations in organs, prominent among which is granulo-fatty 
degeneration of the muscular fibres of the heart. This weakens very much 
the contractile power of the heart. But early in malignant cases, probably 
before the muscular fibres are damaged, the contractile power of the heart is 
feeble from impaired innervation, the result of the general weakness. Hence 
this organ, when weakened by structural change and insufficiently stimulated 
through diminished innervation, may not fully empty itself during the systole, 
and consequently it becomes dilated. Dilatation of the heart and imperfect 
contraction of its auricular and ventricular walls facilitate the formation 
of clots in the cavities of the heart; and this appears to be the immediate 
cause of death in not a few instances. An ante-mortem clot occurring in any 
of the cavities of the heart necessarily seriously obstructs the circulation, 
unless it be of small size. Hence the dyspnoea, which may occur suddenly. 
and the change of pulse to one of marked feebleness and frequency. Large. 
18 



274 CONSTITUTIONAL DISEASES. 

firm white clots are most frequently found in the right cavities. They inter- 
lace with the chordae tendineae, lie even within the auriculo-ventricular open- 
ing, and send prolongations into the pulmonary artery and the cavae. Asso- 
ciated with the white clots are dark, soft clots and fluid blood. The left 
cavities may be contracted and empty, or they may contain dark, soft clots 
or white ante-mortem clots. Clots in the left ventricle are sometimes pro- 
longed into the aorta as far as the brachiocephalic branches, while those in 
the left auricle may extend to the pulmonary veins. If dilatation of the 
heart be so great that clots form in its cavities, speedy death is probable. 
Sometimes a patient passes through scarlet fever and appears in a fair way 
to recover, when he succumbs to some exhausting sequel distinct from the 
heart, and at the autopsy the heart is found dilated and containing whitish 
clots, which are probably ante-mortem, and which hastened death by obstruct- 
ing the circulation. Under such circumstances this state of the heart is 
attributable in great measure to the complication which has weakened its 
contractile power. 

The following was a case in point ; it occurred in the New York Found- 
ling Asylum : 

Case 6. — R. A , aged three years, had scarlet fever, beginning March 23, 

1882. The symptoms were favorable at first, but serious complications and sequelae 
occurred, which were fatal. The record of April 18th reads: ' ; Appears well nour- 
ished, but is anasniic ; has otorrhoea ; no oedema : skin desquamating ; dulness on 
percussion over upper third of right side of chest, anteriorly and posteriorly ; mucous 
rales and rude breathing over same area ; fine rales posteriorly over lower part of 
left side of chest; pulse 160, respiration 68, temp. 101§°." April 2.0th, is feeble 
and takes nutriment with difficulty ; tongue thickly coated ; pulse 160, respiration 
68, temp. 101f°. April 26th, condition about the same as at last record, but he is 
evidently weaker ; the lips are ulcerated and fauces still swollen. May 2d, cannot 
speak distinctly ; a brownish, foul-smelling secretion lodges on the spoon used in 
depressing the tongue ; left side of face swollen. On the following night eight con- 
vulsions occurred, attended by orthopnoea and mucous rales in the chest from pul- 
monary oedema. Diarrhoea supervened and the patient died about midnight. 

Autopsy. — Body moderately wasted and very white ; several dark-blue spots on 
scalp and face from hemorrhages underneath. A careful examination showed the 
presence of broncho-pneumonia in each lung, with considerable infiltration of the 
walls of the bronchi and cylindrical dilatation of many of them ; cavities of the heart- 
dilated, so that this organ appears much enlarged, and its shape approaches the glob- 
ular ; its apex is rounded or obtuse ; transverse diameter of the right ventricle, when 
its walls were open and drawn apart, was three and a fourth inches ; that of the left 
ventricle three and a quarter inches. Similar measurements of the heart of another 
child of about the same age, believed to be normal, were about one inch less in each 
direction. All the cavities contain white firm clots along with soft dark clots. 
Lesions observed in other organs were carefully noted, some of which were serious : 
but the immediate cause of death appeared to be imperfect contraction of the heart 
and the formation of clots in its cavities. 

The nephritis which gives rise to symptoms, and therefore interests the 
practitioner, commonly begins in the declining period of scarlet fever or dur- 
ing the desquamative stage, and is in many instances plainly attributable to 
exposure to cold or to currents of air. It originates either during this period, 
or. if it has previously existed as a mild renal catarrh, it now becomes aggra- 
vated. Dropsy, which always attracts attention, does not occur till the nephritis 
has continued for some time. 

Why nephritis, with the subsequent dropsy, so frequently occurs after 
scarlet fever is not fully understood. Rilliet and Barthez attribute it to dis- 
turbance of the function of the skin. The fact has long been observed that 
the kidneys become affected nearly if not quite as frequently after mild as 
severe cases. Indeed, the chief danger in mild cases, when the patients are 



SCARLET FEVER. 275 

but a short time in bed and are soon allowed to go about, is from the nephritis. 
Chilling the surface and checking cutaneous transpiration appear to be the 
immediate cause of this inflammation in a considerable proportion of cases. 
Therefore, severe attacks of scarlet fever with abundant rash and desquama- 
tion, which require the patient to be kept in bed the proper time and in a 
warm room two or three weeks, appear to be less frequently followed by this 
renal disease than are milder cases which are more carelessly treated. 

The following is a resume of Klein's examinations in twenty-three cases. 

1. Parenchymatous Nephritis, Proliferation of Nuclei, Hyaline Degeneration of 
Arterioles. — The Glomerulo-nephritis of Klebs. — Klein found increase of nuclei 
(probably epithelial) in the glomeruli, and hyaline degeneration of the intiina of 
minute arteries, especially marked in the afferent arterioles of the Malpighian 
bodies. The intima of these vessels was in places as swollen as to resemble cylin- 
drical or spindle-shaped hyaline masses, and cause narrowing of the lumina of the 
vessels in which this degeneration occurred. Klein observed in .some specimens so 
great hyaline degeneration of the capillaries of the Malpighian bodies that circula- 
tion through them was obstructed. In the more advanced or protracted cases this 
hyaline substance in the glomeruli began to assume a fibrous appearance. Bowman's 
capsule was considerably thickened. This hyaline degeneration of the Malpighian 
bodies Klein discovered in the earliest cases which fell under his observation. 

Also in the earliest cases the multiplication or germination of the nuclei of the 
muscular coat of the arterioles was observed, with a corresponding increase in the 
thickness of the walls of these vessels. This change in the muscular element was 
found in the arterioles in different parts of the kidney, but it was most conspicuous 
in these vessels at their point of entrance into the Malpighian bodies ; and it was 
distinctly noticed in other arterioles, both in the cortex and in the base of the 
pyramids. 

In the glandular portion of the kidneys other anatomical alterations were ob- 
served, indicating parenchymatous nephritis. There were swelling of the epithelial 
lining of the convoluted tubes : multiplication of the nuclei of the epithelial cells, 
especially in ascending tubules, which lay close to the afferent arterioles of Malpig- 
hian corpuscles: granular matter, and even blood, in the cavity of Bowman's cap- 
sule and the convoluted tubes ; cloudy swelling and granular disintegration of epi- 
thelium in some parts of the convoluted tubes ; detachment of epithelium from the 
membrane of larger ducts of the pyramids in some cases. These parenchymatous 
changes are already known to the profession through the observations and writings 
of Dickinson, Fenwick, Johnson, Simon, and others. 

Klein, in commenting on the hyaline degeneration which he observed, states 
that Neelsen found the walls of the capillaries of the pia mater thickened, highly 
refractive, and of a lardaceous appearance in certain acute infectious maladies, as 
variola, typhoid fever, measles, and in one case scarlet fever. 1 Usually, only a small 
portion of" the capillaries were thus affected, most frequently at the point of division 
into branchlets. In a few instances Neelsen noticed degeneration of arterioles 
extending a considerable distance, with fusion of the intima, media, and adventitia, 
and chemical examination showed that the substance produced by this degeneration 
had similar properties to elastic tissue. Although the examinations by Neelsen 
relate to the pia mater, two of his observations are especially interesting : first, 
that the hyaline change affects chiefly vessels near their point of branching ; and. 
secondly, that the hyaline substance is of the nature of elastic tissue, for in the 
kidney in scarlatinous nephritis the arterioles undergo the change in question 
chiefly near their point of branching into the capillaries of the glomerulus : and 
the intima being the part which undergoes the hyaline change, it is probable, in 
the opinion of Klein, that the same substance is produced by the degeneration in 
walls of the vessels of the kidney which Neelsen observed in the pia mater, and 
therefore that it is of the nature of elastic tissue. 

This hyaline degeneration of the arterioles is also very marked in the spleen in 
scarlet fever ; and in studying the minute anatomy of the intestines and spleen in 
typhoid fever Klein has found the same degeneration of the intima of the minute 
vessels. He believes that this hyaline change and the proliferation of muscle-nuclei 
which thus occur at an early period in scarlet fever in the renal vessels when the 

1 Archir d&r Heilkunde, 1876. 



276 CONSTITUTIONAL DISEASES. 

kidneys become affected are due to an irritating cause acting similarly to that in 
typhoid fever. 

Klein calls attention to the interesting examinations of the scarlatinous kidney 
made by Klebs, who attributed the diminished urination and the uraemic poisoning 
in certain cases in which the kidneys do not exhibit any marked change to the 
naked eye to what he designates glomerulo-nephritis. Klebs says : "In the post- 
mortem examination the kidneys are found slightly or not at all enlarged, firm, 
.... the parenchyma very hypersernic. Only the glomeruli appear, on close 
inspection, pale like small white dots. The urinary tubes are often not changed at 
all. Occasionally the convoluted tubes are slightly cloudy. The microscopic 
examination shows that there are neither interstitial changes nor proliferation 
of epithelium, the so-called renal catarrh generally supposed to be present in these 
conditions on account of the absence of other perceptible derangements ; and there 
seems, therefore, leaving out the glomeruli, the congestion of the kidneys alone to 
remain to account for the symptoms during life." But that mere congestion is 
insufficient to produce the symptoms appears from the fact that it does not cause 
them under other circumstances. Klebs finds, "on microscopic examination of the 
glomerulus, the whole space of the capsule filled with small somewhat angular 
nuclei, imbedded in a finely granular mass. The vessels of the glomerulus are 
almost completely covered by nuclear masses." 

Klein, commenting on these examinations by Klebs, states that in all early 
cases which he examined he observed great abundance of nuclei of the glomeruli, 
but a condition like that described and figured by Klebs 1 he has seen in only a few 
glomeruli ; for a general state of these bodies as described by this observer, and 
such an excessive proliferation of the nuclei that the blood-vessels are completely 
compressed, was not seen in one of the twenty-three cases. Klein therefore ques- 
tions whether the diminished urination and retention of the urea in scarlet fever, 
when the kidneys do not exhibit any conspicuous catarrhal or other change, is due, 
unless in exceptional instances, to compression of the vessels of the glomeruli by 
nuclear germination, but believes, rather, that the obstructed circulation, and con- 
sequent diminished urinary excretion, are largely due to the changed state of the 
arterioles. Klein adds that perhaps undue contraction of the arterioles, through 
stimulation by the blood-irritant, may also be a factor in causing arrest of circula- 
tion in the Malpighian corpuscles. As regards cases that perished early, he found 
the parenchymatous change slight, so that a careful examination was required in 
order to detect cloudy swelling and granular degeneration. 

2. Interstitial Nephritis. — A second set of changes Klein observed in cases that 
died about the ninth or tenth day. In such cases he found changes due to inter- 
stitial, in addition to those produced by parenchymatous, nephritis. Round cells, 
lymphoid cells, or whatever else they should be called, were seen in the connective 
tissue of the kidneys. In the kidneys of those that died at the end of the first week 
after the commencement of nephritis, infiltration with round cells was observed in 
the connective tissue around the large vascular trunks. At a later stage this infil- 
tration had extended into the bases of the pyramids and into the cortex. The 
gradual increase in extent and intensity of this infiltration was so decided in the 
cases which Klein observed that he has no hesitation in concluding that when 
interstitial nephritis occurs it begins about the end of the first week, in the man- 
ner already stated — to wit, as a slight infiltration of the tissues around the large 
vascular trunks, and gradually extends, so that portions of the cortex, and rarely 
portions of the base of the pyramids, are changed into firm, pale, round-cell tissue 
in which the original tubes of the cortex become lost. 

The infiltration of the cortex with round cells, beginning at the roots of the 
interlobular vessels, spreads rapidly toward the capsule of the kidney, and laterally 

among the convoluted tubes around the Malpighian bodies In the course 

of this process considerable parts of the peripheral cortex, occasionally of a cunei- 
form shape, with the base nearest the capsule of the kidney, become changed into 
whitish, firm, bloodless, cellular masses, in which Malpighian corpuscles and uri- 
nary tubes are only imperfectly recognized, being more or less degenerated. In 
some cases attended by this infiltration of the cortex Klein observed a more or less 
dense reticulation of fibres, especially around the interlobular arteries, containing 
in its meshes lymph-cells, chiefly uninuclear. 

1 Handbuch der Pathol., p. 646, fig. 72. 



SCARLET FEVER. 277 

In a child of five years that died after a sickness of thirteen days Klein found 
evidence of intense interstitial inflammation, and also emboli, consisting of fibrin 
with a few cells, in the arteries, both in those of large size and in the arterioles, 
chiefly where they enter the Malpighian corpuscles. He states that in the speci- 
mens which he examined the more intense the degree of interstitial change, the 
greater was the enlargement of the kidneys, and the more distinct also were the 
evidences of parenchymatous nephritis in the urinary tubes, which either contained 
casts or were in process of destruction. By being crowded with inflammatory prod- 
ucts, especially cells, the Malpighian corpuscles were obliterated, undergoing fibrous 
degeneration. A very curious fact observed was the deposit of lime in the urinary 
tubes, first of the cortex, and then also of the pyramids, at an early stage of scarlet 
fever, when the kidneys otherwise showed only slight change. Several observers, 
as Biermer, Coats, and Wagner, have each described a case of scarlet fever with 
interstitial nephritis, which they consider unusual ; but Klein has apparently demon- 
strated, as we have seen, by a large number of microscopic examinations, that this 
form of nephritis is common after the ninth or tenth day. 

Nephritis, in proportion to its extent and gravity, is accompanied by languor, 
febrile movement, thirst, loss of appetite and strength. At first the patient expe- 
riences but slight pain in the head or elsewhere, and the quantity of urine is not 
notably diminished : but as the disease continues urination becomes less frequent 
and the urine more scanty. Albuminuria occurs, while the urea is only partially 
excreted, and therefore it accumulates in the blood. If the nephritis be so severe 
or protracted that this principle accumulates to a certain extent, grave symptoms 
occur, as headache, vomiting, apathy or restlessness, and, more dangerous than all, 
eclampsia, which is not unusual in these cases. Microscopic examination of the 
urine shows the presence in this liquid of blood-corpuscles, granular epithelial 
cells, and hyaline or granular casts or both. The specific gravity of the urine is 
diminished. But a large quantity of albumen in the urine may render the specific 
gravity as high or higher than in health. 

The altered state of the blood soon gives rise to transudation of serum, first 
observed in most cases as an anasarca occurring in the feet and ankles. The 
oedema, if not checked by treatment or through mildness of the disease, extends 
over the limbs, scrotum, and sometimes upon the trunk. It is well if the dropsy 
remain limited to the subcutaneous connective tissue, but, unfortunately, it is apt 
to occur, if the nephritis continue, in and around the internal organs, producing, 
mentioned in the order of frequency, pulmonary oedema, effusion into the pleural 
and peritoneal cavities, the pericardium, the encephalon, and lastly into the con- 
nective tissue of the larynx, causing that very fatal complication, oedema of the 
glottis. Although this is the common order in which dropsies occur, exceptions 
are not infrequent. Even the anasarca may not be the first to appear, although in 
the vast majority of cases it has the precedence. Thus, Rilliet relates the case of a 
boy of five years who twenty days after the occurrence of scarlet fever, and six 
hours after the appearance of bloody and albuminous urine, had double hydro- 
thorax, rapidly developed. As long as the hydrothorax continued no anasarca was 
observed, but as it declined anasarca appeared. Legendre cites a case in which 
oedema of the lungs occurred without anasarca or other dropsy. Occasionally, the 
anasarca and internal dropsies take place nearly simultaneously. The nephritis 
and consequent serous effusions usually appear within three weeks after scarlet 
fever ends, but cases occur in which the effusions are first observed as late as the 
fourth and fifth weeks. The patient may be considered to possess immunity from 
this sequel if he have reached the close of the fifth week after the abatement of 
scarlet fever without its occurrence. 

The dropsy is usually acute, but it may assume the chronic form, since the 
nephritis which causes it, happily curable in most instances, may, if neglected, 
become chronic. Whether the dropsy in itself involve danger depends in groat 
part on its location. Anasarca and ascites may exist a long time with little suft'er- 
ing or danger, but a small amount of serum in certain other localities causes 
alarming symptoms and speedy death. (Edema of the lungs, hydro-pericardium, 
oedema of the glottis, and intracranial effusions are always dangerous, and the last 
two are sometimes fatal within twenty-four to forty-eight hours. (Edema of the 
lungs has been fatal within twelve hours from the appearance of the first symp- 
toms of obstructed respiration. 



278 CONSTITUTIONAL DISEASES. 

Cerebral symptoms occurring during scarlatinous nephritis are probably 
sometimes due to the irritating effect of the retained urea on the nervous 
centre. In other cases the cause appears to be a cerebral oedema or compres- 
sion of the brain by effusion of serum within the ventricles and upon the 
surface of the brain. Headache, dull or severe, dilatation of the pupils or 
their oscillation in a uniform light, vomiting with little apparent nausea, are 
common symptoms of scarlatinous nephritis when it has continued a few days, 
and the excretion of urea is so diminished that this substance begins to exert 
its poisonous effect on the system. Such symptoms are frequently followed 
by somnolence threatening coma or by eclampsia, unless the patients are 
promptly and properly treated. In some patients that die of scarlatinous 
nephritis, death occurring in convulsions or coma, no appreciable lesions are 
observed within the cranium, unless more or less congestion, the fatal ending 
being attributable to the uraemia. In other instances we find an effusion of 
serum within the ventricles or upon the surface of the brain. Although the 
symptoms in scarlatinous nephritis and uraemia may appear very unfavorable, 
the prognosis is usually good under prompt and appropriate treatment. Thus 
severe convulsions and a degree of somnolence that bordered on coma may 
abate, and convalescence be fully established within a few days. Rilliet and 
Barthez announce ten recoveries in thirteen patients affected with convulsions 
due to this renal affection. 

Anatomical Characters. — Scarlet fever being, as we have seen, a con- 
stitutional febrile disease of an ataxic nature, and accompanied by certain 
inflammations, necessarily affects the composition of the blood ; but since this 
disease varies so greatly in type or severity, the state and appearance of this 
liquid also vary. At the autopsies of the more malignant cases we find the 
blood dark and fluid, with small, soft, and dark clots in the heart and large 
vessels. In other cases the clots are large, firm, and solid, as described in a 
preceding page. In malignant cases that end fatally Rilliet and Barthez 
state that both the large and small vessels of the cerebral meninges and the 
brain are found hyperaemic, but in a variable degree. In those who die in 
coma, preceded by delirium or convulsions, during the eruptive stage the 
intracranial congestion is usually marked, with perhaps some. transudation of 
serum, but without inflammatory lesions. The fibrin in scarlet fever remains 
in about normal proportion, except as it is increased by inflammatory com- 
plications. Andral found an increase in the proportion of blood-corpuscles 
from 127 to 136 parts in 1000. 

The respiratory apparatus, except the Schneiderian membrane, is usually 
normal when no complications exist. Samuel Fenwick 1 made post-mortem 
examination in sixteen cases of scarlet fever, and concludes from them that 
inflammation of the mucous membrane of the stomach and intestines occurs 
like that of the skin, followed by desquamation of the epithelial cells, like 
that of the epidermis. I have had the opportunity of examining the stomach 
and intestines of those who died of scarlet fever in the eruptive stage, and 
have not found any unusual hyperaemia of the gastro-intestinal surface 
except when gastro-intestinal inflammation, usually indicated by diarrhoea, 
had occurred as a complication. 

In some cases the abdominal organs exhibit changes which suggest a 
resemblance to typhoid fever. The spleen is enlarged and somewhat soft- 
ened, and Peyer's patches and the solitary glands are thickened and promi- 
nent, but less in degree than typhoid fever. The mesenteric glands also are 
in a state of hyperplasia. In other patients these parts appear normal. 

Klein made microscopic examination of the liver in eight cases, and states 
that he found granular opaque swelling of liver-cells, and changes in the 

1 London Lancet, Julv 23, 1864. 



SCARLET FEVER. 279 

internal and middle coats of certain arteries similar to those observed in the 
kidneys which have been described above. He also found evidences of inter- 
stitial inflammation, as an increase of round cells and connective tissue in the 
liver. He remarks also that he observed hyaline degeneration of the intima 
of arteries in the spleen. Killiet and Barthez state that swelling and soften- 
ing of the spleen are exceptional in scarlet fever, but are sufficiently common 
to merit attention. In post-mortem examinations which I have witnessed 
nothing noteworthy has appeared to the naked eye in the state of the liver, 
nor ordinarily in that of the spleen. 

The efflorescence, though one of the anatomical characters, has perhaps 
been sufficiently described in the foregoing pages. It begins over the neck, 
chest, and groins as numerous reddish points not larger than a pin's head, 
closely crowded together, but with skin of normal color between. It is esti- 
mated that the aggregate efflorescence and aggregate normal skin over a given 
area are about equal. If the cutaneous circulation be active and the rise 
of temperature considerable, these spots extend and coalesce, producing an 
efflorescence like erythema or like the hue of a boiled lobster, to which it 
has been likened. The efflorescence, less upon the face than upon the trunk, 
contrasts in this respect with that of measles, in which the rash is full in the 
face, often causing some swelling of the features. It is also less upon the 
palmar and plantar surfaces than elsewhere. It scarcely causes any percep- 
tible elevation of the skin, but in certain localities, as upon the backs of the 
hands and upon the forearms, it communicates the sensation of slight rough- 
ness. The seat of the efflorescence is mainly in the superficial layers of the 
skin, but it is said that it sometimes has occurred upon a cicatrix, as that 
from a burn. In the robust and in favorable cases in which the circulation 
is active the rash has a scarlet hue, and when the cutaneous capillaries are 
emptied and the skin rendered pale by pressure with the fingers, the circula- 
tion immediately returns when the pressure is removed. In malignant cases 
the color is not scarlet, but dusky red, and so sluggish is the capillary circula- 
tion that the skin when pressed upon recovers the blood very slowly. In 
grave cases also extravasation of blood in minute points or transudation of its 
coloring matter sometimes occurs in portions of the surface when, of course, 
decolorization is not fully produced by pressure. In cases ending fatally, 
during the eruptive stage the efflorescence may entirely disappear in the 
cadaver, or it remains upon parts of the surface, especially depending por- 
tions. Desquamation is attributable to the exaggerated proliferation of the 
epidermis and the loosening of its attachment by the inflammation. 

Diagnosis. — In the commencement of scarlet fever, prior to the eruption, 
no symptoms or appearances exist which enable us to make a positive diag- 
nosis. Positive statement in reference to the nature of the attack should be 
deferred, for the credit of the physician. Still, if a child with no appreciable 
local disease sufficient to cause the symptoms a few days after exposure to 
scarlet fever, or during an epidemic of this malady, be suddenly seized with 
fever, the pulse rising to 110, 120, or more, and the temperature to 102°. 
103°, or 105°, scarlatina should be suspected. The diagnosis is rendered more 
certain at this early stage if vomiting occur, and especially if the fauces be 
red, for hyperaemia of the fauces, due to commencing pharyngitis, is one of 
the earliest and most constant of the local manifestations of scarlatina. 

When the eruption has appeared the nature of the malady is in most 
instances apparent. The punctate character of the eruption before it 
becomes confluent, its occurrence within twenty -four hours after the fever 
begins over almost the entire surface, its absence or scantiness upon the face. 
and especially around the mouth, serve to distinguish it from other diseases. 

Scarlet fever and measles were long considered identical by the profes- 



280 CONSTITUTIONAL DISEASES. 

sion, and, though the ordinary forms of these maladies can be readily distin- 
guished from each other, cases occur in which the differential diagnosis is 
attended by some difficulty. But there are differences in the symptoms and 
course of the two diseases which aid in discriminating one from the other. 
Measles begins with marked catarrhal symptoms, as if from a severe cold. 
Mild conjunctivitis, causing weak and watery eyes, coryza, and mild laryngo- 
bronchitis, with accompanying cough, precede the eruption three or four days 
and continue during the eruptive stage. The fever during the first or initial 
stage of measles is remittent, the evening temperature being two or three 
degrees higher than that in the morning. Contrast this with the invasion 
of scarlet fever, in which the only catarrh is that of the buccal and faucial 
surfaces, and there is consequently little or no cough, and the rise in tem- 
perature, ordinarily high in the beginning, is nearly uniform in the different 
hours of the day. The scarlatinous eruption appears, as we have seen, within 
twelve to twenty-four hours about the neck and upper part of the chest, and 
spreads over the body in a shorter time than that of measles, which appears 
on the third day. The rash of measles begins to fade at the close of the third 
or in the fourth day after its appearance, that of scarlet fever not till from the 
sixth to the eighth day. In nearly all cases of measles, even when the rash 
is confluent upon the face and a considerable part of the trunk in consequence 
of the high fever and active cutaneous circulation, we observe the character- 
istic rubeolar eruption upon certain parts of the surface, as the extremities ; 
which, in connection with the history, renders diagnosis certain. 

Erythema resembles the scarlatinous eruption, but its duration is com- 
monly shorter. It is limited to a part of the surface, and it is accompanied 
by much less fever. The temperature in erythema does not usually rise above 
100°, unless for a few hours, whereas in scarlet fever it continues several days 
considerably above 100°. The scarlatinous efflorescence has also a brighter 
red or more scarlet hue than that of erythema, except that in the more malig- 
nant cases, in which the severity of the symptoms renders the diagnosis clear. 
But an important aid in differentiating the one from the other of these diseases 
is the fact that in erythema there is, with few exceptions, no faucial inflam- 
mation, and in the few instances in which it is present it is slight and tran- 
sient, fading within a day or two. 

Scarlet fever is readily diagnosticated from diphtheria, although the 
affinity is close between these two maladies. The early appearance of the 
pseudo-membrane upon the fauces in diphtheria, its absence in scarlet fever, 
and the absence of any appearance resembling it until the fever has con- 
tinued some days, and the characteristic efflorescence upon the skin in scarlet 
fever, render diagnosis easy. If scarlet fever have continued some days 
when first seen by the physician, the diphtheritic pseudo-membrane may be 
present as a complication, or the fauces may present an appearance like 
diphtheria from ulceration or sloughing and the presence of foul and offen- 
sive secretions, which produce a dark -grayish and fetid mass over the faucial 
surface. Under such circumstances the character of the disease is ascer- 
tained by the history of the case, and especially by the occurrence of the 
scarlatinous eruption. An erythema transient and limited to a part of the 
surface sometimes appears in the commencement of diphtheria, and at a later 
period, as a result of the toxaemia upon the extremities. Roseoloid points 
and patches often occur upon the extremities. Both kinds of rash can be 
readily diagnosticated from that of scarlet fever, for the erythema, as has 
been stated, is transient and partial, and does not exhibit minute points of 
deeper injection, while the toxasmic rash differs in form and aspect from that 
of scarlet fever, and appears at a stage when the scarlatinous efflorescence has 
faded or begun to fade. 



SCARLET FEVER. 281 

The efflorescence of rotheln sometimes closely resembles that of scarlet 
fever, though it is usually more like that of measles ; but it is ordinarily 
accompanied by symptoms which are much milder than those of scarlet fever, 
and it begins to abate as early as the third, and disappears on the fourth, day. 
The eyes have a suffused appearance, the temperature may reach 102° or 
103°. and the efflorescence may be as general over the body as that of scarlet 
fever, but there is not the aspect of serious indisposition, and the speedy 
abatement of the symptoms shows that the disease is not scarlet fever. 

Prognosis. — The prognosis depends on the form of scarlet fever, whether 
mild or severe, the strength of the patient, and the presence or absence of 
complications or sequelae. The type of the disease is sometimes so mild 
throughout an epidemic or during a series of years that death seldom occurs, 
whatever the mode of treatment ; but afterward the type changes, and the 
percentage of deaths increases and remains high till another amelioration in 
the type occurs. 

Sydenham in the middle of the seventeenth century stated that scarlet 
fever, as he saw it in London, was so mild that it scarcely deserved the name 
of disease : " Yix nomen morbi merebatur." Morton some years later, and 
Huxham in the following century, had abundant reason to regret the change 
of type, and now throughout Great Britain scarlet fever is one of the most 
fatal and most dreaded of the diseases of childhood. In Dublin during the 
present century, prior to 1834, scarlet fever was uniformly mild, so that on 
one occasion of eighty patients in an institution all recovered. In 1834 the 
type of the disease totally changed and epidemics of unusual virulence 
occurred. The type frequently changes from mild to severe or severe to 
mild, not only in consecutive years, but in consecutive months. A few years 
since a distinguished physician of New York treated about fifty cases of scar- 
let fever in one of the institutions without a single death, but a few months 
later the type of the malady changed, and his own son was among those who 
perished from it. The prevailing type of the disease should therefore be con- 
sidered in giving the prognosis when in the commencement of a case we are 
asked the probability as regards the termination. 

Extensive statistics, including those collected by Murchison from various 
sources, show that in different epidemics the mortality may vary as much as 
from 3 per cent. (Eulenberg of Coblentz) to 19.3 per cent, (cases seen by 
myself in New York City in 1881-82, many of which were complicated by 
diphtheria), or even to 34 per cent, (epidemic in the Palatinate in 1868-69). 
The hospital statistics of Billiet and Barthez gave 46 deaths in 87 cases, or 
about 53 per cent. 

The mortality is nearly equal in the two sexes, but age has a marked 
influence on the percentage of deaths. The period of the greatest mortality, 
and also of the greatest frequency, of scarlet fever is between the ages of one 
and six years. The following are statistics bearing on the relation of the age 
to the percentage of deaths : 







Under 1 year. 


From the close 
of 1st till close 
of 5th year. 


From the 5th to 

the 12th 

year. 




Fleishman : 


: Cases 
Deaths 


8 
6 


204 

88 


260 
51 










1st to close of 
6th year. 


6th to 12th 
year. 


From the 12th 
to 20th year. 


Kraus : 


Cases 
Deaths 


. 13 

4 


113 

29 


106 

10 

7th to 16th year. 


40 




Yoit : 


Cases 
Deaths 


5 
1 


166 
24 


109 
10 





282 CONSTITUTIONAL DISEASES. 

From 1st to close 
Under 1 year. of 5th year. Over 5 years. 

Roset: Cases . 43 156 88 

Deaths .16 31 3 

Under 5 years. 5th to 10th year. 10th to 15th year. Over 15 years. 
Russinger : Cases . 101 126 47 27 

Deaths .21 20 3 

These statistics, which I believe correspond with the observations of others,, 
show that although few cases occur in the first year, the percentage of deaths 
is large, and that a majority of the total deaths from this malady occur under 
the age of six years. After the sixth year the greater the age the less the 
proportionate number of deaths. 

Observations have thus far failed to establish any connection in the atmos- 
pheric conditions of temperature or moisture and the type of scarlet fever. 
Grave as well as mild epidemics have occurred in all climates and seasons. 

Scarlet fever is liable to so many complications and sequelae that a phy- 
sician should not predict a certain favorable termination in the beginning, 
however mild and regular the symptoms may be. But a favorable result 
may be expected if the attack be mild, the efflorescence appear at the proper 
time and extend over the entire surface, the angina be moderate and accom- 
panied by little or no cellulitis or adenitis, with pulse under 140, temperature 
not above 103°, and no marked nervous symptoms. 

Whether the complications or sequelae be dangerous depends upon their 
character. Rheumatism has never in my practice been dangerous, nor has it 
materially retarded convalescence, except when it affected the heart, causing 
pericarditis or endocarditis, when it involves great danger. Nephritis, if it 
be moderate, attended by little albuminuria and serous effusion and by the 
occurrence of few renal casts in the urine, commonly ends favorably under 
judicious treatment, as we have already stated ; but severe nephritis, with 
abundant albuminuria and casts and serous effusions, soon gives rise to 
alarming symptoms, and is the cause of death in a considerable number of 
instances. A similar remark is applicable to the angina, which occurs in all 
grades of severity. If it be attended by much cellulitis, with considerable 
ulceration or necrosis, the state is one of danger in consequence of the diffi- 
culty in administering sufficient nutriment, as well as from the diminished 
assimilation and the loss of strength due to the prolonged inflammatory 
fever, the septic poisoning, and the occasional hemorrhages. Complication 
by pharyngeal or nasal diphtheria, now so common where diphtheria is 
endemic, also greatly increases the danger. 

Many cases, even when their course is normal and without complications, 
involve danger, and some are necessarily fatal, from the direct effect of scar- 
latinous blood-poisoning. Such are grave or malignant forms of the disease 
which the experienced eye recognizes at a glance. Death often occurs rapidly 
from the toxaemia. Such cases are characterized by high temperature (105° 
or 106°), rapid pulse, dusky-red hue of the surface from languid capillary 
circulation, pungent heat, frequent vomiting, diarrhoeal stools, a dry-brown 
tongue, and marked nervous symptoms, such as delirium, great restlessness, 
or stupor. Not a few in this form of scarlet fever take eclampsia, which is 
likely to be severe and repeated, and to end in fatal coma. 

Other inflammatory complications and sequelae, which have been described 
in the preceding pages, retard convalescence and jeopardize the life of the 
patient, such as empyema, endocarditis, pericarditis, and pneumonia. Otitis 
media is seldom immediately dangerous, although it may be painful and 
involve serious consequences, even a fatal meningitis, as has been stated 



SCARLET FEVER. 283 

above, after months or years of otorrlioea. Anomalous cases are believed to 
be. as a rule, more dangerous than such as are attended by an early and full 
efflorescence and have the usual symptoms. 

Treatment. — Prophylaxis. — Since the discovery by Jenner of the pro- 
phvlactic power of vaccination as regards smallpox, the attention of the 
profession has been frequently directed to the prevention of scarlet fever. 
Belladonna has been employed for this purpose by a class of practitioners 
who believe in the theory that an agent which produces symptoms similar to 
those of a disease is antagonistic to that disease, and therefore tends to pre- 
vent it. or. if it be present, to render it milder ; and since this herb causes an 
efflorescence upon the skin and redness of the fauces, it was selected as the 
proper preventive and remedial agent for scarlet fever. Its use, however, for 
this purpose has been fruitless, and it is now nearly or quite discarded. 

It is now known, from a considerable number of observations, that scarlet 
fever occasionally occurs in the domestic animals during epidemics of the 
disease in children. It is stated that Spinola observed it in the horse ; that 
Heim saw a dog that occupied the same bed with a scarlatinous patient sicken 
with fever, which was followed by desquamation ; that Letheby saw scarlatina 
in swine, and Kraus in young cattle. Prominent veterinary surgeons, as 
Williams of Great Britain, admit the occurrence of scarlatina in animals, and 
the hope has arisen that since smallpox is modified in cattle so as to afford 
us the vaccine virus, perhaps scarlet fever may also be modified by passing 
through one of the lower animals, so that a milder and less fatal form of the 
disease might be produced in man by inoculation from the animal. Inocula- 
tions have been made to ascertain whether the scarlet fever of animals occurs 
in a modified form, but so far without result. Under the circumstances the 
experimenter who propagates so dangerous a disease by inoculation renders 
himself liable, it seems to me, to criminal proceedings in the courts. 

In the present state of our knowledge the most reliable and certain pro- 
phylaxis is the isolation of patient and nurses and the thorough and judicious 
employment of disinfectants upon their persons and in the apartments. All 
furniture and articles not absolutely required should be removed from the 
sick-room, and no one should be allowed to enter it except the medical attend- 
ant and nurses. Constant ventilation should be insisted on by lowering the 
upper and raising the lower sash of the window two or three inches in mild 
weather. Even in stormy weather sufficient ventilation can be obtained in 
this way without exposing the patient to currents of air, which should be 
avoided. 

The New York Board of Health enforces the following regulations to 
prevent the spread of scarlet fever as well as other acute infectious maladies : 

"Care of Patients. — The patient should be placed in a separate room, and 
no person except the physician, nurse, or mother allowed to enter the room 
or to touch the bedding or clothing used in the sick-room until they have 
been thoroughly disinfected. 

"Infected Articles. — All clothing, bedding, or other articles not absolutely 
necessary for the use of the patient should be removed from the sick-room. 
Articles used about the patient such as sheets, pillow-cases, blankets, or 
clothes, must not be removed from the sick-room until they have been disin- 
fected by placing them in a tub with the following disinfecting fluid : eight 
ounces of sulphate of zinc, one ounce of carbolic acid, three gallons of water. 
They should be soaked in this fluid for at least an hour, and then placed in 
boiling water for washing. 

" A piece of muslin one foot square should be dipped in the same solution 
and suspended in the sick-room constantly, and the same should be done in 
the hallway adjoining the sick-room. 



284 CONSTITUTIONAL DISEASES. 

u All vessels used for receiving the discharges of patients should have 
some of the same disinfecting fluid constantly therein, and immediately after 
being used by the patient should be emptied and cleansed with boiling water. 
"Water-closets and privies should also be disinfected daily with the same fluid 
or a solution of chloride of iron, one pound to a gallon of water, adding one 
or two ounces of carbolic acid. 

ki All straw beds should be burned. 

: ' It is advised not to use handkerchiefs about the patient, but rather soft 
rags, for cleansing the nostrils and mouth, which should be immediately there- 
after burned. 

" The ceilings and side-walls of a sick-room after removal of the patient 
should be thoroughly cleaned and lime-washed, and the woodwork and floor 
thoroughly scrubbed with soap and water." 

By^ such measures of prevention there can be no doubt that the number 
of cases of scarlet fever has been reduced. 

But do the health boards accomplish all that they are able to do in sup- 
pressing scarlet fever as well as diphtheria ? The New York Health Board 
excludes children from the schools who live in the houses where these diseases 
are occurring, gives directions in reference to the care of the patient and the 
disposition of infected articles, and promises to disinfect the sick-room when 
word is sent to the board. But these measures are inadequate or are only 
partially successful in preventing these diseases. To my knowledge, many 
families in New York never send word that they are ready for the disinfection 
of the apartments, and many families in the tenement-houses move away as 
soon as possible. The vacated rooms are re-rented to families who have no 
knowledge of the previous sickness, and are surprised when their children 
immediately after are taken sick. It would be better if the health board in 
every instance disinfected the infected apartments after the termination of 
the sickness, whether the family are willing or not. Moreover, the reader is 
referred to our remarks on the prevention of diphtheria for evidence of the 
inadequacy of the sulphur fumigation. 

But the suppression of scarlet fever cannot be effected without the co-ope- 
ration of the attending physician. He can accomplish more than the health 
board in the way of prophylaxis. More than a quarter of a century has 
elapsed since the late Dr. William Budd of England recommended prophy- 
lactic measures, and the following is his testimony in regard to the result : 
" The success of this method in my own hands has been very remarkable. 
For a period of nearly twenty years, during which I have employed it in a 
very wide field, I have never known the disease to spread beyond the sick- 
room in a single instance, and in very few instances within it. Time after 
time 1 have treated this fever in houses crowded from attic to basement with 
children and others, who have nevertheless escaped infection. The two ele- 
ments in the method are separation on the one hand and disinfection on the 
other." x 

In my opinion it is quite possible to realize the experience of Dr. Budd 
if proper prophylactic measures be employed from the beginning of the sick- 
ness. The attending physician at his first visit and at each subsequent visit 
should consider it an imperative duty to direct the employment of adequate 
preventive measures. Health boards give directions that objects not required 
to promote the comfort of the patient should be removed from the sick-room, 
and no one be allowed to enter it except the physician, nurse, and mother. 
The floor and walls of the apartment should be bare, but I would go farther 
than the health board, and insist that no reading matter, especially books and 
primers, be allow in the room, or if allowed they should subsequently be 
1 British Medical Journal, January 9, 1869. 



SCARLET FEVER. 285 

burnt, since, as we have seen, the specific poison obtaining lodgment between 
the leaves is not readily reached by disinfectants, and may communicate the 
disease months afterward. I recommend for disinfection of the room at my 
first visit, and also for cases of diphtheria, the following prescription : 

R. Acidi carbolici, 

01. eucalypti, da. 5J ; 

Spts. terebinth., 3VJ. — Misce. 

Two tablespoonfuls are added to one quart of water in a tin wash-basin or 
similar vessel with broad surface, and maintained in a state of constant 
simmering over a gas- or oil-stove during the entire sickness. The odor of 
this vapor is agreeable rather than unpleasant, and it appears to disinfect to 
a considerable extent the breath and exhalations from the body of the patient. 
At the same time, I order inunction of the entire surface every third hour 
with the following : 

R. Acidi carbolici, 

01. eucalypti, da. gj ; 

01. olivse, Ivij. 

Dr. Jamieson recommends disinfection of the fauces by the frequent 
application of a saturated solution of boric acid in glycerin. This or 
some other non-irritating solution should be often applied, not only to the 
fauces, but also in the anginose cases to the nostrils. I have recommended 
the application of corrosive sublimate solution, two grains to the pint, applied 
to the fauces by a camel-hair pencil or by cotton wadding wound around a 
slender stick, in the same manner in which Dr. Oatman and others employ it 
in diphtheria. 

The cautious physician in attending a case of scarlet fever will always 
bear in mind the possibility that his person or clothing may become infected, 
and be the vehicle through which the poison may be communicated to others. 
In examining the fauces of a patient he should stand a little to one side, so 
that no muco-pus, if the patient cough, be received on his clothing ; nor will 
he go directly from a scarlatinous patient to a child with another sickness, or 
to a midwifery case, without first washing his hands, hair, and face in a 
corrosive-sublimate solution, and changing his outer apparel ; or if he visit 
a child without such precautionary measures, he will not approach any nearer 
than is sufficient to enable him to determine its ailment and condition. 

Hygienic Treatment. — The room occupied by a scarlatinous patient should 
be commodious and sufficiently ventilated. Its temperature should be uni- 
form, at about 70° during the course of the fever. When the fever begins to 
abate and desquamation commences, a temperature of 72° to 75° is prefer- 
able, so that there is less danger that the surface may be chilled during 
unguarded moments, as at night, when the body may be accidentally uncov- 
ered, since sudden cooling of the surface at this time may cause nephritis or 
some other dangerous inflammation. Henoch does not believe in the theory 
that the nephritis is commonly produced by catching cold, but many observa- 
tions show that those who are carefully protected from vicissitudes of tem- 
perature, who remain during convalescence in a warm room, and are pro- 
tected by abundant clothing, more frequently escape this complication than 
such as are under no restraint of this kind and are carelessly exposed in times 
of changeable weather. Nevertheless, it is true that a certain proportion 
suffer from nephritis however judicious the after-treatment may be. The 
best hygienic management does not always prevent its occurrence. The 
patient should not, therefore, leave the house until four weeks after the 



286 CONSTITUTIONAL DISEASES. 

beginning of the fever, and in inclement weather not till a longer time has 
elapsed. So long as desquamation is going on and the skin has not regained 
its normal function, the patient should remain indoor, and when finally he is 
allowed to leave the house he should be warmly clothed. 

Therapeutic Treatment. — In order to treat scarlet fever successfully, it is 
necessary to bear in mind that it is a self-limited disease, running a certain 
time and through certain stages, and that it is not abbreviated by any known 
treatment. Therapeutic measures can only moderate its symptoms and ren- 
der it milder. The severity of the disease is indicated by its symptoms, and 
the symptoms are to a certain extent under our control. 

Mild Cases. — A patient with a temperature under 103° and with only a 
moderate angina does not require active treatment, but, however light the 
disease, he should always be in bed and in a room of uniform temperature, 
as stated above. Instances have come to my notice in the poor families of 
New York in which scarlet fever was not diagnosticated, and the patients 
were allowed to go about the house, and even in the open air, in the eruptive 
stage, till some severe complication or an aggravation of the type created 
alarm and medical advice was sought, when it appeared that a grave and dan- 
gerous condition had, through carelessness and ignorance, resulted from a 
mild and favorable form of the malady. The physician when summoned to 
a case however mild, should never fail to take the temperature, note the 
pulse, inspect the fauces, and inquire in reference to the fecal and urinary 
evacuations, that he may detect early any unfavorable changes which may 
occur. 

Since in all cases of mild as well as severe scarlet fever more or less 
blood-deterioration and angina are present, the following prescription of the 
tincture of the chloride of iron and pineapple will be found useful : 

R. Tine, ferri chloridi, ^ij ; 

Syrupi ananassa? saliva?, ^v. — Misce. 

Shake bottle. Give one teaspoonful every two hours to a child of three years 

I have long since discarded the potassium chlorate as a local remedy for 
affections of the throat, but the above prescription is beneficial as a tonic and 
astringent. The following is also a useful prescription : 

R. Quinise sulphat. , gr. xyj ; 

Syr. pruni virginiani, 

Syr. verba? santa? comp., da. ^j. — Misce. 

Sig. One teaspoonful every fourth hour to a child of three to five years. 

The treatment of scarlatina by antiseptic remedies will be considered 
hereafter. 

The itching and dryness of the surface, which increase the discomfort of 
the patient in mild as well as severe scarlatina, are relieved by the ointment 
mentioned in treating of prophylaxis. The linen should be changed every 
day and the bed thoroughly aired. 

Ordinary Cases and Cases of Severe Type. — A safe temperature in scarlet 
fever may be considered at or below 103°. If it rise above this, measures 
designed to abstract heat are very important — more important even in many 
cases than the medicinal agents which are commonly used to combat this 
disease. Since a high temperature retards assimilation, promotes deleterious 
tissue-change, and causes rapid emaciation and loss of strength, measures 
designed to reduce it are urgently needed. " The production of heat depends 
chiefly on oxidation of the constituents of the body " (Billroth). Therefore, 
fever indicates an increase of the oxidation and a molecular disintegration 



SCAELET FEVER. 287 

above the healthy standard. Hence the augmentation of urea in the urine 
and the progressive emaciation and loss of weight which characterize the 
febrile state. Fever also diminishes the secretions by which food is digested 
and destroys the appetite, so that repair of the waste is insufficient. More- 
over, a high temperature continuing for a time tends to produce degenerative 
changes, albuminous and fatty, in the tissues, the more rapidly the higher 
the temperature, so that the functions of organs are seriously impaired. 
Among the most dangerous of the tissue-changes is granulo-fatty degenera- 
tion of the muscular fibres of the heart. In dogs and rabbits that have per- 
ished from a high temperature artificially produced by experimenters gran- 
ular clouding of the elementary tissues has been found after death. 1 A high 
temperature, therefore, in itself involves danger, and if it occur in an ataxic 
disease like scarlet fever, and be protracted, it greatly diminishes the chances 
of a favorable issue. As an agent in reducing heat without producing 
depression the following prescription has given in my practice better 
results than any other : 

R. 01. cinnamomi, gtt. v ; 

Phenacetime, J}ij ; 

Sodii bromidi, ^ij ; 

Caffeini citrat., gr. xv ; 

Sacch. lactis, 3j. — Misce. 
Divid. in chart. No. xv. 
To a child of ten years give one powder every three or four hours ; give half a 
powder to a child of five or six years. 

Patients with a high temperature and impending convulsions have been 
rescued by this remedy. 

The temperature can be reduced without shock or injury to the child by 
the judicious use of cold water externally. The cold-water treatment is not 
necessary if the temperature be under 103°, though useful if judiciously 
■employed by sponging when the temperature is at 102° or 103° ; but if it rise 
above 103° it is required, and the more urgently the higher the temperature. 
The external use of cold water as an antipyretic in the febrile diseases is now 
almost universally recommended by physicians, but it still meets with oppo- 
sition on the part of families, especially in the treatment of the exanthematic 
fevers, and the directions for its employment are therefore not likely to be 
fully carried out during the absence of the medical attendant. The old theory 
that the fevers require warmth and sweating has such a firm hold on the 
popular mind that some years longer will be required for its removal. 

The modes of applying cold water recommended by cautious and expe- 
rienced physicians are various. Von Ziemssen recommended that the patient 
be immersed in water at a temperature of 90°, and cool water be gradually 
added till the temperature fall to 77°. In a few minutes the patient is 
returned to his bed, his surface dried, and he is covered by the proper bed- 
clothes, when his temperature will probably be found reduced two or two and 
a half degrees. If the patient complain of chilliness or his pulse be feeble, 
he should be immediately removed from the bath and stimulants adminis- 
tered, either whiskey or brandy, for if the extremities remain cool and the 
capillary circulation sluggish, the effect may be injurious, since some internal 
inflammation may arise to complicate the fever. Under such circumstances 
increased alcoholic stimulation is required. 

The cold pack is also effectual for reducing the temperature. The patient 
is placed upon a mattress protected by oil cloth, and is covered by a sheet 
wrung out of water at a temperature of 70°. This is covered by one or two 

1 See experiments by Mr. J. W. Legg, Lond. Path. Soc. Tnutx., vol. xxiw. and others. 



288 CONSTITUTIONAL DISEASES. 

blankets. In half an hour he is returned to bed, and will be found to have a 
temperature two or three degrees less than that before the bath. Another 
method is to apply the sheet wrung out of water at 90°, and then reduce the 
temperature by adding water at a lower degree from a sprinkler. In most 
cases, however, I prefer to reduce the temperature by the constant applica- 
tion to the head of an India-rubber bag containing ice. The bag should be 
about one-third filled, so that it should fit over the head like a cap. At the 
same time, as a potent means of abstracting heat, at least when the tempera- 
ture is at or above 104°, a similar application should be made by an elongated 
rubber bag lying over the neck and extending from ear to ear. Cold applied 
over the great vessels of the neck promptly abstracts heat from the blood, 
while it diminishes the pharyngitis, adenitis, and cellulitis ; which is an import- 
ant gain. At the same time, it is proper to sponge frequently the hands and 
arms with cool water. If the temperature with this treatment be not suffi- 
ciently reduced, one or two thicknesses of muslin frequently wrung out of ice- 
water should be placed along the arms and upon either side of the face. By 
such local measures, which are agreeable to the patient and without shock or 
perturbing effect on the system, we can reduce the temperature two or three 
degrees. By adding alcohol or one of the alcoholic compounds to the water 
the popular objection to the use of cold is overcome. 

Trousseau, in the treatment of sthenic cases attended by a high tempera- 
ture, was in the habit of placing the patient naked in a bath-tub, and directing 
three or four pailfuls of cold water to be thrown over him in a space of time 
varying from one-quarter of a minute to one minute, after which he was 
returned to bed and covered by the bedclothes without being dried. Reaction 
immediately occurred, often with more or less perspiration. This treatment 
was repeated once or twice daily, according to the gravity of the symptoms. 
Trousseau, alluding to this treatment, says : " I have never administered it 
without deriving some benefit." But the application of cold water in a man- 
ner that does not excite or frighten the patient seems preferable. Henoch, 
having a large experience, gives the following advice in reference to the water 
treatment : "If the fever continue high and the apparently malignant symp- 
toms described above develop, the head should be covered with an ice-bag r 
.... and the child placed in a lukewarm bath, not under 25° R. (88.25° F.). 
I decidedly oppose cooler baths, because in scarlatina, which presents a tend- 
ency to heart-failure, cold may produce an unexpected rapid collapse more 
than in any other affection. But I strongly recommend washing the entire 
body every three hours with a sponge dipped in cool water and vinegar." l 
In grave cases with a high temperature the application of cold should be 
sufficient to produce a decided reduction of heat, otherwise the full benefit 
from its use is not obtained. With proper stimulation and proper precautions, 
prostration does not occur from the ice-bags to the head and neck and cool 
sponging of other parts so long as the temperature does not fall below 102° 
or 103°. The danger alluded to by Henoch can only occur from the use of the 
pack or general bath, and the water treatment can be efficiently carried out 
and the temperature sufficiently reduced without resorting to these. Even 
Currie of Edinburgh, who first drew attention to the benefit from the cold- 
water treatment of scarlet fever in an age when the sweating treatment, and 
even the exclusion of cool and fresh air from the apartment were deemed 
necessary, recommended cold effusion only in sthenic cases with full and 
strong pulse ; and he mentions as a warning two cases with quick and feeble 
pulse and cool extremities in which death occurred immediately after the use 
of the water. 

In severe cases with frequent and rapid pulse, in which ante-mortem heart- 
1 Diseases of Children. 



SCARLET FEVER. 289 

clots are liable to occur, the ammonium carbonate is often useful. It should 
be dissolved in water and given in milk in as large doses as three grains every 
hour or second hour to a child of five years. It aids in producing stronger 
contraction of the cardiac muscular fibres, and thus diminishes the danger 
of the formation of thrombi. Ten-drop doses of the aromatic spirits of ammo- 
nia may be employed instead of the carbonate, given in sweetened water. It 
is especially useful if the stomach be irritable. A wineglassful of milk should 
be employed for this purpose, so that the medicine do not cause gastritis. 

In severe cases attended by considerable angina and foul and offensive 
secretions upon the faucial surface an antiseptic, as boric acid is required. If 
no drink be allowed for a few minutes after the dose, so as not to wash it too 
soon from the fauces, the antiseptic effect is more certainly produced. Those 
old enough should be directed to hold the medicine for a moment like a gargle 
in the throat before swallowing it. I employ boric acid by preference, as in 
the following formula : 

R . Acid, boric, £ss ; 

Tr. ferri chloridi, f^ij ; 

Glvcerini, ) -- ^z- 

Syrupi, |««-fl.lj 

Aquae, f 5 ij . — Misce . 

Sig. Give one teaspoonful every two hours to a child of five years. 

More minute directions will presently be given for the treatment of the 
pharyngitis when we speak of the complications. 

Alcohol, whether administered in one of the stronger wines, as sherry, or 
in whiskey or brandy, is a most useful remedy in scarlet fever, and is indeed 
indispensable in all grave cases which are attended by feeble capillary circula- 
tion and evidences of prostration. Milk is also the best vehicle for this agent. 
The wine-whey or milk-punch should be given every hour or second hour. 
In scarlet fever, as well as diphtheria, comparatively large doses are required, 
as a teaspoonful of whiskey or brandy every hour or second hour for a child 
of five years. 

During convalescence the hygienic treatment already described is import- 
ant. Nutritious diet and a moderate amount of alcoholic stimulants are 
required, while the patient is kept indoor and protected from currents of 
air as long as desquamation is occurring. More or less anaemia is present 
in most convalescent patients, so that a mild tonic containing iron will aid in 
restoring the health. Elixir of calisaya-bark and iron, preparations of beef, 
iron, and wine, or the liquid ferri-peptonati in teaspoonful doses will be found 
useful under such circumstances. Inunction of the entire surface with the 
mixture of carbolic acid, oil of eucalyptus, and sweet oil, as recommended 
above, should be continued as long as the epidermis desquamates. 

Treatment of Complications and Sequelae. — Local measures designed to 
diminish or cure the pharyngitis are important in all but the mildest cases. 
They are more especially required in the anginose variety and in those not 
infrequent cases in which diphtheria complicates scarlatina. Formerly it was 
necessary, in making applications to the fauces, to employ the brush or pro- 
bang for those too young to use the gargle, but hand-anatomizers. as Richard- 
son's or Delano's, which are now in common use, afford a quick and easy 
method for making such applications. Six or eight compressions of the bulb 
of a good atomizer are sufficient to cover the fauces with the spray. Those 
hand-atomizers in the shops which have slender metallic points are likely to 
prick the buccal surface and cause bleeding if the child resist and toss the 
head. To prevent this I recommend the single-bulb atomizer with a simple 
19 



290 CONSTITUTIONAL DISEASES. 

rubber tip. The following will be found useful mixtures for the atomizer 
for ordinary cases : 

R. Creosoti, Morson's Beech wood, gtt. iij-iv ; 

Acid, borici, ,^ij-iij ; 

Glycerini, f^ij ; 

Aquae, f^vj. — Misce. 

R. Carl Seller's Tablet for the Throat, no. j ; 
Creosote, Morson's, gtt. ij ; 

Aquae destillat., 3iij. — Misce. 

Spray either mixture over surface of the throat every two hours. 

If diphtheritic exudation complicate the scarlatinous angina, or the surface 
of the throat in consequence of ulceration or necrosis present an appearance 
like that in diphtheria, when the exudation begins to soften, being foul, 
jagged, of a dirty-brown appearance from dead matter and fetid secretions, 
those mixtures for spraying the throat will be found useful which are recom- 
mended in our remarks relating to the local treatment of diphtheria. 

The following mixture is also beneficial for local treatment when the 
faucial surface is foul and offensive from the exudations and secretions. 
It should be applied by a large camel's-hair pencil every three to six hours : 



. Acidi carbolici, 


gtt. x ; 


Liq. ferri subsulphatis, 


f#j; 


Glycerini, 


,Jj; 

^iij. — Misce. 


Aqua?, 



In all cases of scarlatinous pharyngitis sufficiently severe to require special 
treatment, cool applications should be made over the neck from ear to ear, as 
by two thicknesses of muslin frequently squeezed out of cold water, or by 
the elongated India-rubber bag already recommended in our remarks relating 
to the methods to reduce temperature. 

In the first days of scarlet fever the coryza is slight and no discharge from 
the nostrils occurs, so that no local treatment is required ; but before the ter- 
mination of the malady, in cases of ordinary gravity, a nasal discharge usually 
supervenes, producing more or less redness and excoriating the upper lip. 
Moreover, in localities where diphtheria occurs, if this malady complicates 
scarlet fever, it usually affects the nostrils at the same time that the fauces 
are invaded. These conditions require local treatment of the nares. It should 
be remembered that the Schneiderian membrane is midway in sensitiveness, 
as it is in location, between the conjunctival and buccal surfaces, and is 
readily irritated by strong applications. Medicinal applications made to it 
must be much milder than those which the fauces tolerate. They should 
always be applied warm, and a teaspoonful of any mixture properly employed 
is sufficient for each nostril at one sitting. The applications should usually 
be made every two to four hours, according to the gravity of the case and 
the amount of the discharge. The best instrument for this purpose is a 
small syringe of glass with curved neck and bulbous rubber tip. The 
child's head should be thrown back and the piston depressed rapidly, so as 
thoroughly to wash out the nasal cavity. The application can also be made 
through an atomizer with a rounded tip or a tip covered by rubber tubing. 
The following is a useful prescription : 

R. Acidi borici, gj ; 

Sodii biborat., ,^ij ; 

Aqua? purae, Oj. — Misce. 



SCARLET FEVER. 291 

It is evident, from what lias been stated above, that the condition of the 
ear should be closely observed in and after scarlet fever. If the patient have 
earache, considerable relief may be obtained in the commencement by drop- 
ping a few drops of laudanum and sweet oil into the ear and covering it by 
some hot application, either dry or moist, which will retain the heat. A light 
bag containing common table-salt, heated, or dry and hot chamomile-flowers, 
will also answer the purpose. Water as hot as can be well tolerated dropped 
into the ear or allowed to trickle from a fountain syringe, so as to fill the ear, 
is also very beneficial in allaying the pain. A -I per cent, solution of nitrate 
of cocaine, with an equal quantity of laudanum, dropped into the ear, will 
often give considerable relief. If the hot applications over the ear are not 
well borne. Dr. C. H. May, aurist, recommends applying a long and narrow 
ice-bag immediately behind the auricle and extending under and in front of 
the ear, so as to cover the temporo-maxillary region, and at the same time 
instilling into the ear hot salt water (^j to Oj), to which laudanum or cocaine 
is added. He also states that antipyrine in large doses is also useful in reliev- 
ing the pain. 1 If the pain be not quickly relieved, a leech should' be applied 
at the base of the tragus. 0. D. Pomeroy, an experienced aurist of New 
York, says : " Leeching employed at the right time rarely fails to subdue the 
pain and inflammation. The posterior face of the tragus is ordinarily the best 
place for applying the leech, but it may be applied in front of the ear or 
behind, wherever the tenderness on pressure is greatest. In my opinion, 
paracentesis may frequently be rendered unnecessary by the timely use of 
one or two leeches applied to the meatus." 

If the otitis continue, as shown by pain in the ear, of which children old 
enough to speak bitterly complain, and which causes those too young to speak 
to press their fingers into or against their ears, this inflammation should not 
be neglected, as it may involve serious consequences. Multitudes of children 
have had permanent impairment or even loss of hearing, with caries or necro- 
sis of the walls of the middle ear and of the mastoid cells, which might have 
been prevented by prompt and skilful management of the ear in the early 
stage of the inflammation. If, therefore, the otitis continue without mitiga- 
tion of pain after the above measures have been employed, paracentesis of the 
drumhead is probably required. The following directions for performing this 
operation, which will be useful for country practitioners who may not be able 
to obtain the assistance of a specialist, are furnished by Dr. Pomeroy : " The 
forehead mirror should be worn, in order to leave the hand free to operate by 
either artificial or day light. A good-sized speculum is introduced into the 
meatus. Then an ordinary broad needle, about one line in diameter, with a 
shank of about two inches, such as oculists use for puncturing the cornea, 
should be held between the thumb and fingers, lightly pressed, so as not to 
dull delicate tactile sensibility. The part being well under light, the most 
bulging portion of the membrane should be lightly and quickly punctured 
with a very slight amount of force. The posterior and superior portion of the 
membrane is the most likely to bulge. The chordae tympani nerve ordinarily 
lies too high up to be wounded. The ossicles are avoided by selecting a pos- 
terior portion of the membrane. After puncture the ear should be inflated by 
an ear-bag whose nozzle is inserted into a nostril, both nostrils being closed, 
so as to force the fluid from the tympanum. The puncture may need to be 
repeated at intervals of a day or two, provided that the pain and bulging 
return." 

Albert H. Buck of New York, in a highly instructive paper read before 
the International Medical Congress in 1876, writes as follows of paracentesis 
of the membrana tympani in scarlatinous otitis : ,: In this one slight opera- 
1 Pediatric Sec. of N. Y. Acad, of Med., March 14, 1889. 



292 CONSTITUTIONAL DISEASES. 

tion, which in itself is neither dangerous nor very painful, lies the power to 
prevent the whole train of disagreeable and dangerous symptoms." Buck 
relates an instructive example : The age of the patient was three years, and 
the earache had been complained of only about twenty-four hours. " Toward 

morning," says he, " I was sent for, as the pain had become constant 

An examination with the speculum and reflected light showed an oedematous 
and bulging membrana tympani (posterior half), the neighboring parts being 
very red, though as yet but little swollen. In the most prominent portion 
of the membrane I made an incision scarcely three millimetres (one-tenth 
inch) in length, and involving simply the different layers of the membrana 
tympani. This was almost immediately followed by a watery discharge (with- 
out the aid of inflation), which ran down over the child's cheek. At the end 
of three or four minutes the child had ceased crying, and in less than a quar- 
ter of an hour she was fast asleep. At first the discharge was very abun- 
dant and mainly watery in character, but it steadily diminished in quantity 
and became thicker, till finally, on the fourth day, it ceased altogether. On 
the tenth day the most careful examination of the ear could not detect any 
trace of either the inflammation or the artificial opening." The ear had prob- 
ably been saved from ulceration of the drum membrane, long-continued sup- 
purative otitis, and perhaps permanent impairment of hearing. 

When an opening has been made in the membrana tympani, either by 
incision or ulceration, it is advisable in some instances to inflate the tym- 
panum by Politzer's method, which has been alluded to above. The nozzle 
of an India-rubber bag with a flexible tube attached is introduced into the 
nostril on the affected side, and both nostrils are compressed against it. The 
patient fills his mouth with water, which he swallows at a given signal, as 
after the words one, two, three, spoken by the operator. During the act of 
swallowing, which opens the Eustachian tube, the rubber bag is forcibly com- 
pressed, which forces the air along the tube into the middle ear and facilitates 
the escape of the pent-up secretions in the tympanic cavity. Dr. May recom- 
mends cleansing the nostrils and pharynx with a warm solution of salt, one 
drachm to the pint, before the use of Politzer's bag. 

If the otitis have continued unchecked by treatment until the secretions 
within it, after days and nights of suffering, have escaped by ulceration 
through the drumhead, the opportunity for prompt and certain cure is passed. 
Still, the patient under these circumstances may quickly recover, or there 
may be the other alternative described above, in which the ear is badly dam- 
aged and chronic inflammation established in the walls of the tympanum, 
giving rise to an offensive otorrhcea. In this state of the ear internal rem- 
edies are indicated, such as surgeons employ in suppurative inflammations of 
bone occurring in other parts of the system. Cod-liver oil and iodide of iron 
are required, especially by patients of strumous diathesis, the object being to 
promote a more healthy state of system, so as to prevent extension of the 
inflammation and facilitate the healing process. Carbolized solutions, as the 
following, syringed warm into the ear in which otorrhoea is occurring, are 
useful in promoting cleanliness and increasing the comfort of the patient : 

R. Acidi carbolici, £ss ; 

Glycerini, f:fij ; 

Aquae, f^iv. — Misce. 

But recently an effectual curative agent for local treatment has been discov- 
ered in boric acid, by the use of which the discharge quickly diminishes 
and the condition of the ear more certainly and rapidly improves than by the 
use of carbolized lotions. 



SCARLET FEVER. 293 

R. Acidi borici, gij ; 

Glycerini, 

Aquae, ad. Oss. 

Sig. Instil sufficient to till external ear several times daily. 

The following astringent has also been employed with good results for 
the otorrhoea resulting from scarlet fever as well as from other causes : 

R. Zinci sulphatis, 

Aluminis, da. gr. v ; 

Aquae, 15 j. — Misce. 

A few drops of this should be dropped into the ear, or, if the ear be sensitive 
and painful, five drops should be added to a teaspoonful of warm water and 
dropped or syringed into the ear. 

But in recent times aurists have discovered in iodoform a remedy, the 
action of which is safe and efficient for protracted otorrhoea with granula- 
tions. The ear should first be thoroughly cleansed by syringing with warm 
water and dried, and iodoform, to which a little balsam of Peru is added to 
mask the disagreeable odor, should be pressed down to the bottom of the 
auditory canal by any convenient instrument, It is anodyne, astringent, and 
disinfectant, and should be employed in a dry state in considerable quantity. 

The sequelae of otitis media, such as granulations sprouting out from the 
drumhead, some of which may be of large size and are known as polypi, may 
require treatment by the aurist. A polypus may sometimes be removed by 
the forceps, or, better, by the snare. Polypi not large and favorably located 
can sometimes be cured by an astringent powder, as iodoform, sulphate of 
zinc, alum, or aristol. The otitis externa produced by the irritating dis- 
charge which flows from the middle ear soon disappears when the flow ceases. 

The renal affection — which, as we have seen, so often commences in the 
declining period of scarlet fever or during convalescence, in mild as well as 
severe cases — is frequently more dangerous than the primary disease. It 
largely increases the percentage of deaths. A clear appreciation of its thera- 
peutic requirements is important, since by judicious treatment many recover 
who would inevitably be sacrificed by improper measures. The family should 
be informed that the danger from scarlet fever does not cease with the decline 
of the eruption, and that the kidneys may become seriously affected by too 
early exposure of the patient to currents of air or sudden changes of tem- 
perature, by which cutaneous transpiration is checked. He should therefore 
be kept indoor in a comfortable and uniform temperature three or four weeks 
after the termination of the fever, until desquamation has entirely ceased and 
the new epidermis is sufficiently thick and firm to protect the surface. Dur- 
ing the changeable temperature of the autumnal, winter, and spring months 
even longer confinement at home may be advisable. 

The nephritis and consequent albuminuria antedate by some days the occurrence 
of dropsy, and a physician should never discharge a scarlatinous patient without one 
or more examinations of his urine. When his visits cease the nurse should be in- 
structed to make the examinations by heat and nitric acid during the ensuing 
month, and if any evidence, however slight, appear that the kidneys are involved, 
he should be notified, in order that appropriate treatment may be immediately com- 
menced. Early and correct treatment of the nephritis is attended by much better 
results than delayed treatment, and many more patients are doubtless now saved 
than in former times, when little attention was given to the state of the kidneys 
until dropsy or other prominent symptoms appeared. I have found no mother or 
nurse so ignorant that she could not properly employ the test of nitric acid and 
heat, and if she be solicitous for the welfare of the child, she will not hesitate to 
carry out the directions and immediately notify the physician if the tests employed 
produce the least cloudiness or turbidity of the urine. 



294 CONSTITUTIONAL DISEASES. 

The patient as soon as nephritis commences, as shown by the state of the urine, 
should be put to bed in a room of warm and equable temperature (72° to 75° F.). 
His diet should be liquid, consisting of milk, farinaceous food, and a moderate 
quantity of animal broths. He may drink liquids freely, especially water not too 
cool, to which spiritus aetheris nitrosi is added. If he be prostrated by the primary 
disease, alcoholic stimulants should be allowed. 

The indications are to relieve the hypergemic kidneys by diaphoresis and purga- 
tion. To produce the former the patient should be immersed in a warm bath at 
about the temperature of the body (98° to 100°), in which, if he be quiet and com- 
fortable, he should remain from fifteen to twenty minutes, but a shorter time if 
restless and frightened by the water, after which he should be placed in a warm 
bed and well covered by blankets. If perspiration result, the bath has been useful, 
and it may be employed in grave cases two or three times daily. If perspiration 
do not result, it may be produced by surrounding the body either by hot dry or 
moist air. Hot air may be produced by burning alcohol in a thin layer upon a 
plate under a chair, upon which the patient sits while he is surrounded by a 
blanket, or he may be covered in bed and the hot air introduced under the bed- 
clothes. In New York a convenient apparatus is used for this purpose, consisting 
of a small sheet-iron pipe enclosed in a small box of the same material. The box 
is in the form of a trunk, with a handle for convenience in carrying, and the lower 
end of the pipe, which extends nearly to the floor, contains an alcohol lamp. Hot 
moist air may be produced by placing against the patient bottles of hot water sur- 
rounded by towels wrung out of water. The steam arising from them and envelop- 
ing the body and limbs produces a prompt sudorific effect. There is in use in this 
city, in the treatment of these and similar cases requiring diaphoresis, a convenient 
apparatus for generating steam. It consists of a cylinder pierced with holes for the 
admission of air and containing a spirit lamp, over which is a pan or pail holding a 
little water. The patient, nearly naked, is placed in a chair with the apparatus 
underneath, and is covered by a blanket, so that the steam surrounds the body. 
This gives rise to free perspiration, which continues after the patient is placed in 
bed. This treatment should be repeated one or more times daily, according to the 
gravity of the case. 

The sudorific effect of the treatment by external warmth described above 
should be aided by employing diaphoretics. Those which have been most 
used are the acetates of ammonium and potassium, the bi-tartrate and citrate 
of potassium, and spiritus aetheris nitrosi. If employed when the surface is 
cool they act rather as diuretics than diaphoretics. These agents, being 
simple in their action and without deleterious effect, may be given frequently 
and in large proportionate doses for the age. 

But lately a diaphoretic which far surpasses these in efficiency has been 
discovered in pilocarpine, the active principle of jaborandi. Being soluble in 
water and tasteless, it is easily administered, and is retained when, on account 
of the uraemic poisoning present in scarlatinous nephritis, the stomach is 
irritable and other medicines, as digitalis, are rejected. Ether may be 
employed with it, or the amount of alcoholic stimulant may be increased 
at the time of its exhibition in order to guard against any depressing effect. 
To a child of two years one-fortieth to one-twentieth of a grain may be given 
every six hours by the mouth. It may also be employed hypodermically, as 
one-twentieth of a grain to a child of five years. It has both a diaphoretic 
and a diuretic action, while it stimulates both the salivary and mucous secre- 
tions. According to one observer, an adult when fully under the influence 
of pilocarpine secretes from one pint to one quart of saliva within two hours, 
and Leyden reports a case of diphtheritic nephritis in which the quantity of 
urine rose from half a pint to five pints daily. But its most prompt and 
certain action is upon the sweat-glands. Hirschfelder speaks of its beneficial 
action in relieving various forms of dropsy, and adds : " In one morbid con- 
dition of the kidney, however, jaborandi is the remedy par excellence, and 
that is the acute parenchymatous nephritis which frequently follows scar- 



SCARLET FEVER. 295 

latina This disease heals spontaneously if the danger that threatens 

life from reduction of the urine and from the effusions of fluid into the cav- 
ities of the body be averted. In this disease jaborandi works wonders." I 
have also found it an invaluable agent when the older remedies failed and 
death seemed imminent. The following cases, in which the beneficial action 
of this agent was apparent, occurred in my practice : 

Case 1. — G , male, aged live years and six months, sickened with scarlet 

fever on June 2, 1882. It began with vomiting, and was attended by a degree of 
fever which indicated an attack of rather more than the average gravity. The 
fauces at one time exhibited a slight exudation like that of diphtheria. In the 
declining stage of the malady rheumatic pain and tenderness occurred in the wrist- 
and finger-joints, but not in those of the lower extremities. The case, however, 
progressed favorably, and during the convalescence my attendance ceased. On 
June 24th my attention was again called to the child, when the urine was found to 
be scanty and very albuminous. External measures, such as are described in the 
foregoing pages, were employed, and the infusion of digitalis with potassium acetate 
ordered to be given every three hours ; but this medicine was for the most part 
vomited. The bowels were kept open by jalap and the potassium bitartrate. The 
urine, however, continued scanty, and on June 28th severe convulsions occurred. 
At this time the quantity of urine was only f^ij in twenty-four hours. The pulse 
in the convulsions was quick and feeble, the skin very hot, and the axillary temp. 
103°. The eclampsia continued one hour, and was controlled by large and repeated 
doses of bromide of potassium, aided by clysters of five grains of hydrate of chloral 
in water. Muriate of pilocarpine was now directed to be given in doses of one- 
thirty-second of a grain every three hours, dissolved in cold water. This agent 
was not vomited, and it must have been given by the parents in their fright 
and anxiety in larger or more frequent doses than were directed, for on July 1st 
the bottle containing one grain was empty. Free diaphoresis resulted from the 
pilocarpine, and the quantity of urine was increased. The mother stated that the 
child had taken only two doses, or one-sixteenth of a grain, of pilocarpine when 
the diuretic effect was apparent and free diaphoresis also occurred. She also stated 
subsequently that the quantity of urine was larger when the pilocarpine was ad- 
ministered every third hour than when given at a longer interval. A flaxseed 
poultice on which mustard was dusted was also applied over the kidneys. On June 
20th the pulse was 96, temperature 100.5° ; occasional convulsive attacks occurred, 
which were readily controlled by enemata of hydrate of chloral. On June 30th the 
symptoms were all better ; no more attacks of eclampsia had occurred, and the urine 
was more abundant and less albuminous. The mother remarked that the new 
medicine (pilocarpine) had settled the stomach and increased the urine. The 
patient continued to improve, and on July 4th the record states : " Now takes the 
pilocarpine, gr. ^, every six hours ; passes urine freely since yesterday ; has not 
vomited since he began to take the pilocarpine ; pulse 106, axillary temp. 99°; is 
playful and takes milk freely, nearly three quarts in twenty-four hours, with some 
farinaceous food. Digitalis with potassium acetate is also given in occasional 
doses." July 6th, pulse 92, temp. 99°; perspires much, and urine nearly normal 
in quantity a,nd character. 

Case 2. — Mary S , aged five years, on Dec. 22, 1882, presented the symp- 
toms of severe nephritis. Her brother had scarlet fever two weeks previously, and 
she had sore throat at about the same time, but without efflorescence ; pulse 98, 
temperature 98.5°; her urine highly albuminous, and reduced to f^iv in twenty- 
four hours 5 bowels constipated. Ordered a single dose of 

R. Hydrarg. chlor. mitis, gr. iij ; 

Resin, podophyll., gr. \. — Misee. 

The muriate of pilocarpine was also ordered, gr. ^ (T , but the patient vomited soon 
after taking it. Another dose was retained, and was followed by considerable per- 
spiration. Dec. 23d, had one stool from the powder of yesterday, lias taken five 
doses of pilocarpine, but vomited after three of them. The last dose was adminis- 
tered at 10 p. m., and the mother says she " sweat fearfully *' during the night. The 
patient was kept warm in bed ; stimulating poultices oi' mustard and flaxseed, one 



296 CONSTITUTIONAL DISEASES. 

to sixteen, were constantly in use over the kidneys, and the pilocarpine was admin- 
istered three or four times a day. The record for Dec. 26th states: "Took the 
pilocarpine four times since yesterday morning, and each dose is followed by per- 
spiration lasting from one to one and a half hours ; quantity of urine, from f^vj 
to f^viij daily ; vomited twice yesterday, not to-day ; pulse 104 ; temp. 97.75° ; 
complains of frontal headache ; bowels regular ; has considerable salivation. The 
patient is warm in bed, and the flaxseed and mustard poultice over the kidneys is 
continued. ,; Dec. 28th, specific gravity of urine 1019 ; urine still quite albuminous 
and containing blood-corpuscles and granular casts, also crystals of oxalate of lime. 
Dec. 30th, takes gr. 2V pilocarpine twice daily, and occasional doses of infusion of 
digitalis ; urine more abundant ; its specific gravity 1014, slightly albuminous, and 
containing very few granular casts and blood-corpuscles ; has lost its smoky appear- 
ance ; reaction alkaline ; perspiration slight ; patient convalescent. 

In another instance a child of five years, from three to four weeks after 
scarlet fever, was noticed to have anasarca of the face and extremities, with 
scanty and albuminous urine. One thirty-second of a grain of muriate of 
pilocarpine was administered every six hours without the desired sudorific 
effect. It was then administered every four hours, with an increase of per- 
spiration and urination, so that the nephritic symptoms were relieved and the 
patient apparently out of danger within three or four days. 

In a fourth patient, a girl of three years having scarlatinous nephritis, 
with symptoms very similar to those in the last case, the administration of 
one-twentieth grain doses of pilocarpine in conjunction with the hot-air bath 
was followed by increased perspiration and urination, and progressive and 
rather rapid convalescence. This child had been taking bichloride of mercury 
in one-fiftieth grain doses, prescribed by a homoeopathic physician, without 
appreciable benefit, it having been for the most part vomited. 

Given, as in the above cases, in moderate doses and with sufficient inter- 
val, pilocarpine has never in my practice had any deleterious effect, and I 
regard it as a very important addition to the remedies for the relief of scar- 
latinous nephritis. It is apparently the most useful and important diaphoretic 
for this disease which we possess, but .pilocarpine is a dangerous remedy if 
not given in the proper small doses and at proper intervals. It has pro- 
duced a fatal bronchorrhoea by too large a dose, of which I was a witness ; so 
that it must be given in small doses and its effects closely watched. 

Cathartics, especially those of a hydragogue nature, are also very bene- 
ficial. Their action is more certain than that of most diaphoretics and diu- 
retics, and their employment is imperatively required in severe or dangerous 
cases in which it is necessary to remove as soon as possible the serum or urea 
which endangers life. Young children or those with delicate stomachs and 
those much enfeebled by the primary disease may take magnesia, either the 
citrate or the calcined. A good cathartic for ordinary robust cases is a mix- 
ture of jalap and potassium bitartrate, the pulvus jalapse compositus, consist- 
ing of one part of jalap and two of cream of tartar. Ten grains of the mixture 
may be given to a child of five years, and repeated according to circum- 
stances. Its effect is increased by dissolving a teaspoonful of potassium 
bitartrate in a gobletful of water and allowing the patient to drink from it. 
The following cathartic also acts promptly and beneficially in the treatment 
of scarlatinous nephritis : 

R. 01. cinnamomi, gtt. v; 

Magnes. sulphat., Jf j ; 

Potass, bitartrat., gij. — Misce. 

Dose : One teaspoonful repeated from two to four hours until catharsis occurs. 

After the use of laxative agents the kidneys, being less congested on 
account of the diversion that has occurred, often begins to excrete urine 



SCARLET FEVER. 297 

more freely. But if the patient be anaemic or enfeebled and the symptoms 
are not urgent, it is frequently better to avoid active catharsis, which more 
or less reduces the strength, and employ remedies of a sustaining character, 
as in the following case, which occurred in my practice : A little boy, pallid 
and scrofulous, began to have anasarca after scarlet fever, chiefly in the scro- 
tum, accompanied by a moderate degree of ascites. The urine, which was 
passed in nearly the normal quantity, contained albumen, but not in large 
amount. This patient gradually and fully recovered, with no treatment 
except the use of an oil-silk jacket over the kidneys and abdomen to pro- 
mote diaphoresis, and the use of iron. Such a patient, treated by the power- 
ful eliminatives which we employ for the more urgent and robust cases, would 
probably have been injured rather than benefited. No treatment can there- 
fore be recommended in a treatise on scarlatinous nephritis which will be 
strictly applicable for all cases. Variations are demanded according to the 
state of the patient and the form and gravity of the disease. 

Diuretics which do not stimulate the kidneys are proper at an early as 
well as late period of the renal malady. The following is a favorite diuretic 
in the New York City Hospital : 

R. Potass, acetat., 1 

' ' bicarbonat. , >- da ^ij ; 

" citrat., J 

Infus. tritici repentis, £iv. — Misce. 

Give one teaspoonful every two hours. 

One teaspoonful of the infusion may be given every third hour to a child 
of five years. The following formula is for one of the same age in good 
general condition. It should be given in water : 

R. Potass, acetatis, Jss ; 

Infus. digitalis, f^ vj. — Misce. 

Give one teaspoonful from two to four hours. 

Local treatment is important. In the majority of cases instead of depletion 
a poultice slightly irritating, so as to cause redness of the skin, should be 
applied over the kidneys, or for older children, not likely to be frightened by 
the process, the dry cups may be applied daily. In subacute cases, not 
attended by any alarming symptoms, sufficient redness may be produced by 
the external use of one part of turpentine and two of camphorated oil. 

Eclampsia, described in the preceding pages, is produced, as we have seen, 
during the course of scarlet fever by the irritating effect of the scarlatinous 
poison upon the nervous centres ; but, occurring after the decline of scarlet 
fever, it is ordinarily produced by the retained urea. The same remedies are 
required to control the convulsive movements as when they occur under 
other circumstances. The bromide of potassium should be immediately 
administered in large doses whenever eclamptic symptoms arise. During 
eclampsia a child of three years should take five grains of this agent every 
five to ten minutes till the attack ceases, and then at longer intervals. The 
hydrate of chloral is a more powerful agent, and if the eclampsia be not 
quickly controlled, I commonly employ it per rectum, dissolved in one or two 
teaspoonfuls of water. For a child of three to five years five grains should 
be thrown into the rectum by a small glass or gutta-percha syringe, and 
retained by pressure. Properly administered and retained, it rarely fails to 
control the eclampsia within ten or fifteen minutes. Subsequently, occa- 
sional doses of the bromide should be given to prevent the occurrence of 
eclampsia while the measures described above are being employed to elimi- 
nate the urea. 



298 CONSTITUTIONAL DISEASES. 

Rheumatism, endocarditis, and pericarditis, arising as complications or 
sequelae, require the treatment which is appropriate when they occur under 
other circumstances, but the remedies should not be depressing, as the sys- 
tem is already enfeebled by the primary disease. The rheumatism, if mild, 
usually abates in a few days without medication, and the affected joints 
require only some soothing lotion and support by a bandage. The following 
liniment may be applied upon muslin and covered by cotton wadding : 

R. 01. caryophylli, ^ij ; 

Tine, belladonnse, fjjj ; 

01. camphorati, f^iij. — Misce. 

If the rheumatism be severe and affect several joints, the sodium salicylate 
should be prescribed, as in the idiopathic disease, with an occasional opiate to 
procure rest. 

Endocarditis and pericarditis require rest in the horizontal position, avoid- 
ance of all excitement, the use of the tincture or infusion of digitalis or the 
tincture of strophanthus to procure a slow and steady action of the heart. 
Three drops of the tincture of digitalis or one to one and a half drops of 
the tincture of strophanthus may be given every four hours to a child of five 
years. The same external measures should be employed as in acute pleu- 
ritis. I prefer the application of a thin poultice of flaxseed containing one- 
sixteenth part of mustard and covered with oiled silk. The cardiac inflam- 
mations, as well as rheumatism, require opiates in sufficient doses to procure 
rest and sleep. 

In some instances strychnia, gr. t -J-q to a child of eight years, is the better 
heart tonic. 

Pleuritis, which we have stated is often suppurative, demands the same- 
treatment as the idiopathic disease when it occurs in cachectic patients. 



CHAPTER III. 

ROTHELN. 

This disease has also been designated rubella, epidemic roseola, rosalia r 
rubeola notha, and German measles. Some recent writers incline to the 
belief that it occurred in Europe in the eighteenth century, having the name 
rubeola. Thomas states that, according to Formey, 457 died from rubeola, 
172 from scarlet fever, and 53 from measles in Berlin in the decade beginning 
with 1784 ; but he also states that many who observed these epidemics be- 
lieved that the rubeola was a species of measles. We infer that this was the 
correct opinion, and that the rubeola of the eighteenth century was not the 
rotheln of the present time, since the latter is almost never fatal, except from 
complications. In Great Britain, from the year 1840 onward, various writers, 
when treating of measles and scarlet fever, make statements which lead us to 
think that they may have sometimes mistaken epidemics of rotheln for modi- 
fied forms of measles or scarlet fever. Perhap"s it is not too much to claim 
that the first clear and distinct differentiation of rotheln was made in this 
country. Cases of rotheln occurring in and about Boston were described by 
Dr. Homans. Sr.. in 1845, and at a later date — to wit, in 1853 and 1871 — B. 
E. Cotting and Mr. D. Howard saw cases, and described them in papers read 



ROTHELN. 299 

before local societies (Bast. Med. and Surg. Journ., March 15, 1873). In 
1S74. Dr. Caleb Green of Homer, Cortland co., New York, an accurate and 
intelligent observer, also witnessed an epidemic of this disease. 

Rbtheln was not. however, noticed in American treatises, and it scarcely 
received recognition in America, until an epidemic of it occurred in the Xew 
York Foundling Asylum and in New York City in 1873-7-1, which furnished 
the material for a paper published in the Archives of Dermatology in 1874. 
This epidemic began in the latter part of 1873, and attained its maximum in 
March and April, 1874, after which it gradually declined. This, so far as I 
can learn, was the first occurrence of rbtheln in this locality. In a general 
practice of more than twenty years, extending over a considerable portion 
of this city. I had previously seen nothing like it, and other older physicians, 
having a large general practice, informed me that they considered it an en- 
tirely new disease with us. Those who believed that they had occasionally 
observed isolated cases of it previously to this epidemic probably referred to 
roseola. 

The first case which I observed occurred in the middle of December, 
1873, in West Seventy-first street, in the northern suburbs of New York. 
A few weeks later cases were so numerous in the more thickly-populated 
section of the city as to attract the attention of many physicians. It was 
evident that a disease had appeared with which we were not familiar, and 
as the eruption occurred in points and small circumscribed patches, it was 
usually designated by the physicians, in want of a more accurate name, 
epidemic roseola, or was spoken of as a spurious measles. Physicians who 
were familiar with foreign medical literature saw the resemblance between 
these cases and those of rbtheln as described by British and continental 
writers, but in certain at least of the foreign cases the duration of the rash 
was said to be seven days (Liveing, London Lancet, March 14, 1874, and 
Med. Xeirs and Library, May, 1874), whereas in the cases in New York it 
commonly disappeared by the fourth day. This discrepancy, however, was 
not sufficient to invalidate the belief in the identity of the New York disease 
with the foreign rotheln. It was readily explained by the difference in the 
seasons in which the cases occurred, for Liveing observed his cases in June 
and July, and, as we will see, the greater the external heat the longer is the 
duration of the eruption. 

Between the middle of December, 1873, and May 1, 1874, 1 had observed 
and treated this malady in eighteen families. Cases occurred in three other 
families living in the same houses with some of those which I attended, and, 
as they were fully and clearly described to me, so that there could be no doubt 
as to their nature, I have included them in my statistics. The total number 
of cases in these twenty-one families was 48. During May, when the epi- 
demic was declining, I saw 6 additional cases, occurring singly, making a total 
of 54. Their ages are given in the following table : 

Age. Cases. 

From eight months to one year - 

11 one year to two years 4 

" two years to five years 16 

" five years to ten years 23 

" ten years to fifteen years 3 

" fifteen years to thirty years J} 

Total number of cases 51 

The age of the youngest patient was eight months and that of the oldest 
thirty years: 72 per cent, of the total number were between the ages of two 
and ten years, so that rotheln is pre-eminently a disease of childhood. Indi- 



300 CONSTITUTIONAL DISEASES. 

viduals in and beyond the middle period of life seem to have nearly an immu- 
nity from it. The age of the oldest patient of whom I was informed in the 
epidemic of 1873 and 1874 was about forty years. On March 25, 1873, during 
my attendance in the New York Foundling Asylum, rbtheln appeared in a 
boy of four years ; in the following month about thirty more cases occurred 
in this institution, all children, while among the large number of female nurses 
and employes, who were chiefly between the ages of twenty and thirty years, 
all but three escaped. 

From 1874 to 1880 rotheln did not prevail in New York, unless now and 
then an isolated or sporadic case, the nature of which was not recognized 
and which was supposed to be roseola. On August 9, 1880, two cases 
appeared in different wards of the New York Foundling Asylum, when it 
was remembered that two weeks previously these children had been exposed 
to a patient in the hospital attached to the institution who had what the phy- 
sician in attendance supposed at the time to be roseola. 

Commencing with these two cases, an epidemic occurred in the asylum, 
mild in type, affecting only a few at a time, but extending over several 
months, until about sixty inmates, chiefly children, were attacked. Toward 
the close of 1880 rotheln began to appear in the northern part of the city, 
in which the asylum is located and over which my practice extends. Its 
maximum prevalence was attained in the latter part of March and April, 
1881, when it particularly attracted the attention of physicians. A large 
proportion of the children attending certain public and private schools were 
attacked. It occurred in seventeen families in my practice. The ages of the 
patients in these families are given in the following table : 

Age. Cases. 

From one to two years 3 

" two to five years 8 

" five to ten years 18 

" ten to fifteen years 11 

There were two cases over fifteen years, aged respectively twenty-two 

and forty-two years _2 

Total number of cases 42 

Premonitory Stage. — Premonitory symptoms are in most instances 
absent or so mild as to attract but little attention. It not infrequently 
happened in the New York epidemics that the parents or the teachers in the 
schools were first made aware of the illness of the children by observing the 
eruption. In some instances children were sent from school, not because they 
felt too ill to remain, but on account of the unusual appearance of the skin. 
Sometimes, however, in those old enough to express their sensations a pre- 
monitory stage of some hours or a day, or even of longer duration, was 
present, consisting of such symptoms as usually occur when one has taken 
a severe cold, as languor, pain in the head, trunk, or limbs. The resident 
physician of the New York Foundling Asylum was so ill with rotheln that 
he was confined to his bed during the first day of the disease. Now and then 
patients experience nausea previously to the eruption and in the first and 
second days of the eruptive stage. In only one instance did I observe grave 
prodromic symptoms. A boy aged eight years was suddenly seized with clonic 
convulsions, and while in a warm bath for the relief of these the rash appeared 
upon those parts of the body which were immersed in water. 

Symptoms. — Tegvmentary System. — (a) The Skin. — The eruption com- 
monly commences upon the forehead, around the ears, and along the neck, 
as in measles. Occasionally it may appear upon the back or chest, as in the 
above-mentioned case, in which the hot water accelerated its appearance. 



BOTHELN. 301 

Commencing above, the efflorescence travels downward, appearing after some 
hours upon the lower part of the trunk and on the legs, resembling in this 
respect the eruption of measles and scarlatina. It occurs upon all parts of 
the integument except the scalp and palmar and plantar surfaces. In the 
majority of the cases which I have seen it gradually faded away, disappear- 
ing by the fourth day, but in children who were kept warm in bed or in 
warm apartments it remained longer than on others. In many instances 
traces of the rash were still visible several days after recovery when the 
patients were heated by exercise or excitement. It reappeared at times, 
though indistinctly, on a girl of thirteen years for three weeks. In most 
of the cases in the New York epidemics the eruption commonly occurred in 
points and circular spots somewhat smaller than those of measles. These 
points and spots were numerous and thickly set, so that, in the aggregate, 
the}* covered at least half of the surface, while between them the skin pre- 
seDted nearly or quite its normal appearance. The general aspect in most 
cases was more like that of measles than that of scarlatina, but in exceptional 
instances the skin between the points and spots had a redness similar to that 
of erythema, and the resemblance was very like the scarlatinous efflorescence. 
Thus, in a boy of three years the eruption so closely resembled the scarlat- 
inous over the trunk that were it not that the temperature was constantly 
below 100°, and the fever entirely ceased within three or four days, I would 
probably have considered the malady a mild scarlatina. In certain patients 
the eruption, beginning in circumscribed spots, like that of measles, becomes 
in two or three days confluent, so as to resemble that of scarlatina, while 
over other parts the spots remain discrete. This was the character of the 
eruption upon the third and fourth days on the extremities of a little boy in 
the Foundling Asylum. The rash is attended by considerable itching, from 
which, indeed, many patients suffer more than from all other symptoms. 

The eruption disappears on pressure, produces a slight roughness of the 
surface, as ascertained by passing the fingers gently over it, and usually fades 
away without desquamation. Exceptionally, there is a slight branny exfolia- 
tion, and in one of my patients the exfoliation was as great over the abdomen 
as in cases of scarlatina. 

(6) The Mucous Membrane. — In connection with the cutaneous eruption 
a mild inflammation also occurs upon the mucous membrane covering the 
fauces, buccal cavity, and nostrils, and upon reflections of this membrane 
over the eyes and eyelids — i. e., upon the conjunctiva. In certain patients 
this inflammation is scarcely appreciable, but in the majority it arrests atten- 
tion at once. It produces a suffused, reddish, or weak appearance of the eyes, 
with a moderately increased lachrymation. On everting the eyelids the pal- 
pebral conjunctiva is seen to be injected. In certain patients a moderate puri- 
form secretion collects at the inner angle of the eyelids. In occasional cases 
the conjunctivitis causes oedema of the lids, usually slight and likely to be 
overlooked by the physician ; but in three instances which I now recall to 
mind the mothers of the children directed my attention to the swollen state 
of the lids. In one of these, an infant of twenty-three months, the tumefac- 
tion was so great, commencing about the time the eruption began to fade. 
that light was totally excluded from the eyes and it was impossible to ascer- 
tain their condition. The skin over the eyelids retained nearly its normal 
appearance, and a puriform secretion appeared between the lids. In three 
or four days the oedema of the lids and the hyperemia of the conjunctiva 
declined. The coryza is in most cases sufficient to cause an unpleasant sen- 
sation in the nostrils and provoke sneezing; but the flow from the nostrils. 
though present, was in no instance under my observation as abundant as in 
ordinary cases of scarlatina or even of measles. The fauces present an injected 



302 CONSTITUTIONAL DISEASES. 

appearance, and in severe cases there is moderate swelling of the tonsils. The 
same catarrhal hyperaemia is also seen in spots or patches, more or less diffused, 
upon the buccal surfaces. Both the faucial and buccal catarrh are less in 
degree, however, than in cases of rubeola and scarlatina, which have an equal 
intensity of cutaneous eruption ; and this fact aids in differential diagnosis. 

The Respiratory System. — In both the epidemics which I have witnessed 
the mucous membrane of the larynx, trachea, and bronchial tubes participated 
only slightly in the inflammation which involved the nasal, buccal, and faucial 
surfaces. Many of my patients had no cough, but others had a mild cough, 
lasting a few days, but with normal respiration. It was due apparently to a 
very mild catarrh of the respiratory tract at the time when the nasal and 
conjunctival surfaces were the most affected. It subsided in a few days 
without treatment. In no case do I recollect that there was any hoarseness. 

The Digestive System. — The tongue in roth el n is moist and of normal 
appearance or covered by a slight fur. The appetite may be impaired, but 
is not wanting in uncomplicated cases. The patients sometimes say that it is 
nearly the same as in health ; the thirst is slight, and the bowels are regular. 

Nausea is not infrequent, and vomiting was, in several cases in my prac- 
tice, one of the initial symptoms. In certain patients it also occurred on the 
first or second day of the eruption. In others there was no nausea, so far as 
I could learn, either immediately before or during the prevalence of the 
disease. This symptom is less frequent in rotheln than in scarlet fever, but 
is as common apparently as in measles. I have never found albumen in the 
urine, though I have examined that passed by several patients. This secre- 
tion did not appear to be abnormal except as it contained urates, so common 
in febrile states. 

The Pulse and Temperature. — The largest number of accurate daily obser- 
vations relating to the temperature was, I think, that of Dr. Reid in the New 
York Foundling Asylum during the month of March, 1874. He has kindly 
furnished me with his statistics relating to this symptom, as follows : c ' The 
number of closely-observed cases in which the temperature was taken was 
24. In 17 of the cases the temperature ranged from 97° to 99° ; in 6 it 
reached 100°, 100£°, and lOOf ° ; in 1 it reached 103i° on the second day 
of the eruption, but remained so elevated only one day." In certain patients 
Dr. Eeid observed what he designates " a tendency to the development of an 
ephemeral fever." These observations correspond closely with those made by 
myself during the same epidemic. Thus, in 16 cases I found the axillary 
temperature taken each day to be constantly between 98° and 100°, with a 
pulse under 110, except in 1 case, in which it numbered 124. In certain 
other patients a more decided rise in temperature from one to two or three 
days occurred, usually in the commencement of the malady. Thus, a girl 
aged three and a half years had a temperature of 101 f° and a pulse of 128. In 
another instance the pulse was 124 and the temperature 102°. In another, 
a girl of three and a half years, considerable fever occurred without apparent 
cause on Saturday night, but it abated on the subsequent day. She seemed 
well until the following Tuesday, when the fever returned and the eruption 
appeared. On Thursday the temperature from 102° to 103° fell to 99*°, 
and within a day or two she was convalescent. In two other patients from 
two to four days after the disappearance of the eruption an accession of fever 
occurred, lasting about one day, and attended by pain and distress in the 
epigastric region, but without vomiting or diarrhoea. In one of these the 
temperature was 103f °, the pulse 130 per minute. In the other case the tem- 
perature and pulse did not seem to be under these figures, but were not 
accurately ascertained. Occasionally the fever is due more to complications 
than to the primary disease. Thus, in two of my patients the rise of tern- 



ROTHELN. 303 

perature was mainly attributable to diphtheritic inflammation which had 
attacked the fauces. But while the fever in rotheln is ordinarily of short 
duration, in certain patients temporary exacerbations may occur in which the 
temperature is as high as in scarlet fever or measles. 

Complications ; Prognosis. — The only complications which occurred in 
cases in my practice have already been alluded to — to wit, diphtheria, which, 
when prevalent, usually attacks surfaces already inflamed. In the Foundling 
Asylum varicella complicated one case and pneumonia another. In a third 
pneumonia occurred about three days after the disappearance of the eruption. 
The prognosis in uncomplicated cases is always very favorable, and there is 
no liability to sequelae more than in mild catarrhal inflammations of a non- 
specific character. The duration of rotheln is short, not ordinarily extending 
beyond three to five days. 

Nature ; Incubative Period ; Contagiousness. — Is rotheln a distinct 
malady, or one with which we are familiar, but the form and character of 
which are modified by unusual meteorological conditions? Is it roseola 
assuming at certain periods an epidemic character and appearing to be con- 
tagious ? Or is it at all times infectious, possessing a specific principle, and, 
like other infectious diseases, self-propagating ? Should it in nosological 
classification be placed among the non-contagious and local or among the 
constitutional and infectious maladies ? Let us consider the facts observed 
in the New York epidemics. 

The first cases of rotheln in this city were often designated roseola by the 
physicians called to treat them, since they seemed to resemble more closely 
this disease than any other with which they were familiar. But rotheln 
differs widely from the peculiar form of dermatitis known as roseola. The 
successive occurrence of the eruption over the upper and then the lower 
parts of the body, but covering the whole surface, and the definite duration 
of three to five days, are points of difference. Moreover, roseola would not, 
without so great a change in its character as to become virtually a distinct 
disease, occur in the cool months, without any appreciable dietetic cause, as 
an epidemic over a certain area and for a limited time, affecting whole house- 
holds and sparing other households as well as individuals of a certain age. 
We therefore consider it distinct from roseola. 

Most of the cases of the New York epidemics bore considerable resem- 
blance to measles, both as regards the appearance and duration of the erup- 
tion and the catarrh of the mucous surfaces. Parents often diagnosticated 
measles before the arrival of the physician, and the physician himself, at first 
glance, sometimes made the same diagnosis. But in rotheln the shortness 
and mildness of the stage of invasion, the absence of cough or the presence 
of one trivial and scarcely noticed, appetite good or but slightly impaired — 
in fine, symptoms that are transient or slight — afford a striking contrast to 
the graver symptoms of measles. But the decisive proof that rotheln is not 
a modified measles is found in the fact that one does not prevent the other. 
Of the 48 cases observed by myself prior to May 1st in the epidemic of 
1874, 19 at least had had measles, and 1 who had rotheln took measles sub- 
sequently. I have already stated that in the New York Foundling Asylum 
rotheln in 1873 and 1874 closely followed an epidemic of measles. A con- 
siderable number of the children attacked by the former disease had recently 
recovered from the latter. During the epidemic of 1880 and 1881 the same 
fact was observed — namely, that a previous attack of measles as well as 
scarlet fever afforded no protection from rotheln. Dr. Chadbourne, the resi- 
dent physician, writes of the cases in the Foundling Asylum in 1880 ami 
1881 : " Eight children had rotheln who had had both scarlet fever and 
measles within six months under my observation, while certain others had 



304 CONSTITUTIONAL DISEASES. 

had these diseases at some previous time." Of the cases observed by myself 
in family practice in the same epidemic, it is stated in my notes that ten had 
had measles. These statistics are sufficient to show that rotheln is a distinct 
disease from measles, however close the kinship. 

That rotheln is not a form of scarlet fever is evident from the fact that 
as regards at least the New York epidemics the rash was in most instances 
quite distinct from the scarlatinous efflorescence, occurring, as we have said, 
in small more or less circular points and patches. Moreover, as we have 
remarked above, there is in rotheln a slight febrile movement and general 
mildness of symptoms which contrast with the high fever and other pro- 
nounced symptoms of scarlatina, or if there be considerable febrile move- 
ment its duration is brief. But the conclusive proof of an essential differ- 
ence between these two diseases is found in the fact already stated in refer- 
ence to measles, that the attack of the one malady does not prevent the 
occurrence of the other. There are, it is true, cases in which it is difficult at 
first to make the differential diagnosis between rotheln and mild measles or 
mild scarlet fever, but when the course of the malady has been closely 
observed for three or four days, it will rarely happen, I think, that we will 
be unable to make out its character. 

Those cases of an epidemic which arise when the causes or conditions 
from which it has developed are most strongly operative, and which at this 
time are likely to be typical, obviously afford the best data for studying its 
nature. Such were the 48 cases which I saw in the epidemic of 1873 and 
1874, and the 42 in that of 1880 and 1881. As regards the former epi- 
demic, in thirteen of the twenty-one families embraced in my statistics the 
first cases were children who up to the time of the seizure were attending 
public and private schools, and in certain instances those who were nearly 
simultaneously attacked, living perhaps in streets widely separated, were 
attending the same school. During the epidemic of 1880 and 1881 the first 
patients in thirteen of the eighteen families in which rotheln occurred in my 
practice were school-children between the ages of six and twelve years, and 
in most, if not all, the different schools which they attended rotheln was at 
the time prevailing as an epidemic, as I ascertained on inquiry. It therefore 
seemed probable that these children whom I attended had contracted it from 
others in the schools. 

In both the New York epidemics during the time that rotheln was at its 
maximum prevalence, in most of the families containing two or more chil- 
dren the cases were multiple, not occurring simultaneously, but in succes- 
sion, as if the malady were contracted from those first affected. This is what 

we daily witness in the spread of exanthematic fevers. Thus in Mr. E 's 

family a girl attending one of the public schools took rotheln in the middle 
of December, 1873 ; the two remaining children sickened with it one week 
and two weeks later. A niece visiting in the family at the time when the 
first child was sick, but returning home to another street, also had the erup- 
tion on December 27th. Alice II , aged ten years, a frequent visitor at 

Mr. E 's, living in the same street, and several times exposed to his 

children during their illness, also took rotheln about January 4th. West 
Seventy-first street, where these cases occurred, was thinly settled and subur- 
ban, and I could learn of no other cases in the vicinity. A child of Mr. 

P , aged five and a half years, had been in the habit of playing with two 

children two doors away, who became affected with rotheln in the beginning 
of April, 1881. On April 14th he was supposed to have a mild coryza from 
taking cold, as he sneezed often, but in a few hours the efflorescence appeared. 
Four days subsequently, on the 18th, an infant was affected in the same way, 
and thirteen days later another child in the family, aged twelve years. In a 



ROTHELN. 305 

similar manner rotheln occurred in the families of two brothers living in 
adjoining houses in West Fifty-first street. The first patient was a boy of 
twelve years. It appeared successively in the children of these two families 
until ten had been affected. In a family in West Forty-sixth street the first 
case was a boy attending a school in which rotheln was prevalent. Within 
twenty days — namely, between March 31st and April 20th— four other chil- 
dren were attacked in succession. 

These facts and cases seem to demonstrate the contagiousness of rotheln, 
at least during the time in which the conditions are most favorable for its 
development or during the time in which the epidemic influence is most pro- 
nounced. In the declining period of both the New York epidemics the cases 
which I observed occurred for the most part singly, although there was no 
attempt to isolate the patients, so that the contagiousness of the disease 
must be slight. 

Kotheln is, in my opinion, an exanthematic fever feebly contagious. 
It resembles varicella in general mildness of symptoms, in the absence 
of dangerous complications or sequelae, and in the uniformly favorable 
prognosis, while its symptoms show a resemblance to measles and scarlet fever. 

If the above view be correct, rotheln must possess an incubative period 
which, in the cases observed in both epidemics, apparently varied between 
seven, or perhaps less than seven, and twenty-one days. Its incubation, 
therefore, like that of scarlet fever and diphtheria, apparently varies in 
different patients. In the cases which came under my notice the incubative 
period, when it could be accurately ascertained, was more frequently about 
two weeks than a longer or shorter period. The resident physician of the 
New York Foundling Asylum, when the epidemic was prevailing in that 
institution, returned to his home in the State of Maine to a locality where 
rotheln was unknown. Fourteen days from the date of his departure he was 
himself affected with the disease in its typical form. No other case occurred 
at his home, where probably the atmospheric conditions were unfavorable. 

Minnie B , attending a school in which there were many cases, had the 

rash on April 5th. On the 23d of the same month, eighteen days afterward, 
it appeared upon the servant who was frequently in Minnie's room. Elizabeth 

C , attending a school in which rotheln was prevailing, had the eruption 

on April 17th. It commenced upon her sister thirteen days, and upon her 
mother fourteen days, subsequently. 

Other cases might be cited of an apparently shorter as well as longer 
incubative period. The following note from Dr. Chadbourne of the New 
York Foundling Asylum, bearing upon the subject, is interesting: "I am 
led to believe from my observations that the period of incubation was, in the 
majority of cases, from twelve to fifteen days. The disease has been very 
feebly contagious. In some cases one child would have rotheln, while the 
other, nursed by the same woman, escaped. In two instances women had 
the disease, and though each suckled two infants, the latter escaped." Osborn 
states that enlargement of the small glands at the edge of the hair on the 
postero-lateral sides of the neck has been present in all the cases which he 
has observed, and he therefore considers it an important diagnostic sign 
( Weekly Med. Rev., Dec. 24, 1887). Several other writers have also observed 
this glandular enlargement, and some have stated that it occasionally pre- 
cedes the efflorescence. Swelling of the lymphatic glands in other parts of 
the system has also been recorded by different observers, and it rarely goes 
on to suppuration. It usually subsides with the disappearance of the rash, 
but Golson has observed the occurrence of abscesses in the site of the sub- 
maxillary lymphatic glands. Curtman has also observed the formation of 
abscesses in various parts of the body. 
20 



306 CONSTITUTIONAL DISEASES. 

Complications. — Recent writers have recorded a considerable number 
of complications and sequelae, the more important of which we will briefly 
enumerate as follows, but the occurrence of some of them was a coincidence : 
Severe bronchitis, pneumonia, pleurisy, enteritis, entero-colitis, colitis, icterus, 
stomatitis, rheumatism, meningitis, abscesses, miliaria, pemphigus, erysipelas, 
oedema, enlargement of the thyroid, otorrhoea, earache, and keratitis. Some 
of these complications are such as frequently occur in measles, to which, as 
we have seen, rotheln bears considerable resemblance. 

Diagnosis.— Roth eln might readily be mistaken for roseola if only a few 
and isolated cases occur, but the longer continuance of the eruption, the 
catarrhal symptoms, though slight, and in most instances the evidence of 
contagion, enable us to make the diagnosis. From measles this disease is 
distinguished by the absence of, or slight and transient character of, the 
prodromal stage. The fever with evening exacerbations, the cough, and pro- 
nounced catarrhal symptoms, which precede the rash in measles three or four 
days, do not occur in rotheln. The diagnosis from mild scarlet fever in the 
commencement of an epidemic, when only a few cases are observed, may be 
difficult, but no epidemics of scarlet fever occur in which the type remains 
so mild as in rotheln. The shorter duration of the rash, the absence of the 
initial vomiting and of the strawberry tongue, the usual roseolar rather than 
erythematous character of the rash, the mildness, sometimes scarcely appre- 
ciable, of the stomatitis and pharyngitis, the slight indisposition, so that the 
child, if it followed its inclination, would not be under restraint, and the 
absence, with few exceptions, of complications and sequelae, usually render 
the diagnosis from scarlet fever clear and unmistakable. 

Prognosis. — Death does not occur except from some complication or 
intercurrent disease. When Forney stated that in Berlin during the decade 
ending with 1794, 457 died from rubeola, 172 from scarlet fever, and 53 from 
measles, he could not by the term " rubeola " have referred to rotheln, as 
some have supposed, or the nature of the disease has totally changed. More- 
over, in the literature of rotheln the assigned causes of death have been, in 
my opinion, in some instances, concurrent or accidental maladies which did 
not result from this disease. 

Treatment. — In the majority of cases the medicinal treatment should 
be of the mildest kind or none at all. As death has occurred from bronchitis 
and pneumonia supervening upon rotheln, the patient should remain in a 
room of equable temperature, and not be exposed to currents of air. Any 
local ailment which may arise or any intercurrent disease should of course 
be promptly treated, since death may occur from them, while the primary 
disease is not fatal and is even trivial. 



CHAPTEE IV. 

VARIOLA— VARIOLOID. 



Variola, or smallpox, is a specific febrile affection, accompanied by a 
vesiculo-pustular eruption upon the skin. Since the discovery of the pro- 
tective power of vaccination it has been shorn of much of its terror, but it 
is still the most loathsome and most dreaded of all the fevers. Two forms 
of this disease are recognized, depending on the fact whether there have been 
previous vaccination. If the patient have been vaccinated at some period in 



VARIOLA — VABIOL OID. 307 

his life, the disease, which is rendered milder in consequence, is designated 
varioloid. If there have been no vaccination, it is called variola or smallpox. 
Both forms are identical in nature, the one communicating the other ; they 
differ only in gravity. 

From accounts still extant — which, however, are vague — this disease 
appears to have prevailed at a remote period in China and Hindostan. It 
was carried across the Asiatic continent by caravans engaged in the silk-trade, 
reaching Europe in the sixth century. Its extension to countries previously 
free from it has been mainly through commerce and invading armies. It is 
stated that it reached England in the thirteenth century and Germany and 
Sweden in the fifteenth century. It was introduced into Mexico by the 
invading army of Cortez, where for years afterward heaps of skeletons of 
those who had perished by it were found in shaded localities. 

Etiology. — Although pathologists do not doubt the microbic origin of 
variola, the microbe which causes it has not yet been clearly ascertained. 

Smallpox presents four stages : the initial, or that of invasion ; the erup- 
tive ; that of desiccation ; and, lastly, that of desquamation. It is termed 
discrete when the pustules remain separated from each other ; confluent when 
they unite. This division is made according to the charactor of the eruption 
upon the face and hands. There are parts of the surface, as the abdomen, 
where the pustules are always discrete, even in the confluent form. 

Incubative Period. — During the last half of the last century inocula- 
tion with variolous matter was extensively practised in Great Britain and on 
the Continent, as it was found that smallpox thus communicated was milder 
than when received by infection. This operation enabled physicians to deter- 
mine the period of incubation, which was found to be from eight to eleven 
days. When variola is communicated through the air the incubative period 
is somewhat longer — to wit, from twelve to fourteen days. 

Stage of Invasion. — Smallpox begins abruptly with chilliness. In 
children of an advanced age there is often, as in the adult, a distinct chill. 
This is followed by fever and such symptoms as usually accompany a high 
temperature — to wit, lassitude, anorexia, and thirst. In addition, certain 
symptoms arise which, though not peculiar to smallpox, are so marked in 
the commencement of this disease that they possess considerable diagnostic 
value. These symptoms, which pertain to the nervous system and occur in 
the initial stage of varioloid as well as variola, are severe frontal headache, 
pain in the small of the back, and great drowsiness, sometimes with delirium. 
In many children convulsions occur, preceded and followed by a degree of 
stupor which is almost as profound as coma. Trousseau suggests the name 
rachialgia for the pain in the back, since he believes that it is located in or 
around the spinal cord. This belief is based on the fact which he, and other 
observers have noticed, namely, that there is sometimes in connection with this 
symptom an incomplete paraplegia, indicated by numbness of the legs or even 
inability to use them, and sometimes more or less paralysis of the bladder. 
These paraplegic symptoms pass off in a few days. Vomiting is also a com- 
mon symptom in this stage, and one also of diagnostic value. It occurs at 
short intervals for twenty-four to thirty-six hours, The same symptom is 
common in scarlet fever, and not infrequent in measles, but in both these 
maladies irritability of stomach is much less persistent than in smallpox : 
vomiting does not occur in normal rubeolous and scarlatinous cases more than 
once or twice. 

The tongue is covered with a moist fur. If the disease is to be discrete, 
constipation is commonly present in the stage of invasion ; if confluent, diar- 
rhoea is a common symptom, continuing till the fourth or fifth day. or even 
longer. Roseola or erythema sometimes occurs in this stage, and this may 



308 COXSTITUTIOXAL DISEASES. 

lead to error of diagnosis, the disease being mistaken for one of these cutane- 
ous affections or even for scarlet fever. The symptoms in the stage of inva- 
sion are usually more violent in confluent than in discrete variola, but there 
are exceptions. 

Stage of Eruption. — The eruption commences about the third day, 
earlier in some cases, later in others. The average duration, therefore, of 
the first stage is somewhat shorter than in measles, but considerably longer 
than in scarlet fever. Sydenham has stated — and observations show the 
truth of the remark — that the shorter the first stage the more severe the dis- 
ease will prove to be ; and, conversely, the longer the period the milder will 
be its form. Therefore, if the eruption begin on the second day, it will, as a 
rule, be confluent : if not till the fifth or sixth day, it will be scanty and the 
disease light. 

The eruption commences in minute red spots, somewhat like those of 
lichen, which gradually enlarge. It is first observed around the lips and 
upon the neck, then upon the face, scalp, upper part of chest, arms, and 
finally upon the lower part of the chest, the abdomen, and legs. It is some- 
times, especially in young children, first observed in the folds of the skin, as 
about the genitals or in the groin. If the cuticle be irritated, as by a sina- 
pism, the eruption often appears first upon this part of the surface and in 
greater abundance than elsewhere. Commencing in a minute reddish point, 
as stated above, it rapidly enlarges, and soon its central part begins to be 
indurated and raised. It feels round and hard to the finger, is tender, and 
its diameter does not ordinarily exceed two lines. This is the papular stage. 
The papulae increase and become more elevated, and in twenty-four to forty- 
eight hours from the commencement of the eruptive stage they become vesic- 
ular. On the fifth day of the eruption, or eighth of the disease, the vesicle 
has attained its full size. Its diameter is then about one-fourth of an inch 
and its elevation is two or three lines. Its base is circular and indurated, 
and it is surrounded by a narrow zone of inflammation, indicated by redness 
and tenderness of the skin. The pock commonly, as it passes from the papu- 
lar to the vesicular stage, loses its acuminate form, and becomes depressed in 
the centre, but in most cases mixed with the umbilicated vesicles are some 
which remain acuminate. 

In proportion as the eruption becomes developed in discrete variola and in 
varioloid, the symptoms which accompanied the stage of invasion abate ; the 
fever, headache, pain in the back, and thirst cease, and the appetite returns. 
In the confluent form the fever continues with little abatement. 

Simultaneously with the eruption upon the skin an eruption also occurs 
upon the buccal and faucial surfaces, and often upon that of the air-passages. 
It occurs sometimes, also, upon the conjunctiva, producing dangerous oph- 
thalmia, and even ulceration with loss of sight, and upon the mucous sur- 
face of the genital organs. The form which it presents upon mucous sur- 
faces is somewhat different from that upon the skin. There is at first a 
deposit of fibrin, producing a small, round, grayish spot at the point of erup- 
tion — firm, slightly elevated, and covered, if not by the entire mucous mem- 
brane, at least by its epithelial layer. Ulceration soon occurs, as in ulcerous 
stomatitis, and if the patient live the reparative process succeeds, as in simple 
ulcers. The eruption upon mucous surfaces increases considerably the suffer- 
ing of the patient, in consequence of the tenderness of the ulcers ; and if its 
seat be the surface of the larynx or trachea, it may be the immediate cause 
of death, especially in young children, by obstructing respiration. 

The cutaneous eruption has been traced to the vesicular stage. On or 
about the fifth day of the eruptive period, or eighth of smallpox, the ves- 
icles gradually change their character, their contents becoming thicker and 



VARIOLA— VARIOL OID. 309 

turbid. At the same time they increase still more in size and the central 
depression disappears. This is designated the stage of maturation or of sup- 
puration, though it is known that the turbidity is due chiefly to another 
substance than pus. The pock, having undergone these changes, is termed 
the pustule. 

In discrete variola and in varioloid the fever returns during the pustular 
stage, or if the form of the disease be confluent and the fever have continued, 
it now becomes more intense. The return of the fever or its increase is 
denoted by increased frequency of pulse, elevation of temperature, dryness 
of skin, anorexia, and thirst. A tendency to constipation remains throughout 
in varioloid and discrete variola ; in the confluent form diarrhoea more fre- 
quently occurs, which, if it continue, is an unfavorable prognostic sign. 

Other changes occur. The pustules increase somewhat in size and become 
more globular. Some of them, when most distended, break through friction 
of the clothes or scratching of the child, and their contents, escaping, add to 
the loathsomeness of the disease. There is in the pustular stage more or less 
redness of the surface between the eruptions, and, except in the mildest cases, 
tumefaction from subcutaneous infiltration occurs. In the confluent form at 
this period the features are often so swollen that the friends would not recog- 
nize the patient. The eyelids may be so cedematous that the eyes are for a 
time concealed from view. This oedema of the surface is not altogether absent 
in the vesicular stage, but it increases during the time of maturation, after 
which it subsides. 

Stage of Desiccation. — This immediately succeeds the full development 
of the pustules. The liquid portion of the contents of the pustules which 
are broken evaporates, leaving a crust. If there be no rupture, the liquid is 
absorbed and a scab results, which, though smaller, preserves in a measure 
the form of the pustule. While the pustule desiccates the surrounding inflam- 
mation rapidly abates. The crusts occur first upon the face, and on other 
parts in the order in which the eruption appeared. The odor from the patient 
at this time is peculiar. In the confluent form especially it is very offensive, 
and can be noticed at a distance from the bedside. Rilliet and Barthez call 
it nauseous and fetid. As desiccation progresses the symptoms, local and 
general, abate. The pulse and temperature, if the case be favorable, return 
to the normal ; the cough, hoarseness, and thirst disappear, while the appetite 
returns ; the sleep is more tranquil, and the functions generally are more 
regularly performed. 

The last stage is that of desquamation ; it commences between the 
eleventh and sixteenth days. The scabs, which present a dark or brownish 
appearance, are successively detached. This period lasts several days ; some- 
times two or three weeks even elapse before all the crusts separate. In the 
meantime, the patient gradually recovers his health and former strength. 
After the fall of the crust the cicatrix underneath presents a reddish appear- 
ance. The color gradually fades, and there remains an irregular depression, 
or pit, of a lighter color than the surrounding surface, and, if there have 
been a full development of the eruption, it disfigures the patient for life. 

Such is the clinical history of variola when it is favorable and its course 
is regular. The disease is sometimes irregular. In rare instances the erup- 
tion occurs almost at the commencement of the attack. The form is then 
likely to be confluent. There are irregularities also in consequence of diarrhoea, 
hemorrhages, or other complications. I have known the eruption appear first 
on the limbs, and last on the trunk and face, and the appearance of the erup- 
tion is not always the same. In the anaemic and feeble child it often presents 
a pale color, with some induration at its base, but without the red areola 
around it or with this quite indistinct. In rare instances the vesicles have a 



310 CONSTITUTIONAL DISEASES. 

reddish color, their contents being tinged with blood. This form of variola 
is designated hemorrhagic. It indicates a profoundly altered state of the 
blood. The eruption in this form is of small size, and if the pock is broken 
blood oozes from it. 

I have met one case, perhaps two, of malignant hemorrhagic smallpox, as 
described by Hebra, among the rare forms of this malady. The second case 
died so soon that we were undecided whether he had smallpox or scarlatina. 
A man aged thirty-six years, previously healthy, became suddenly and severely 
sick in June, 1881, with fever, intense headache and backache, great depres- 
sion of the vital powers, sleeplessness, and a sensation of sinking or depression 
in the epigastrium. He had a marked foreboding of coming evil, and begged 
almost constantly for relief. Within forty-eight hours a heavy and continuous 
dusky scarlatiniform eruption covered the whole surface, except below the 
knees, disappearing on pressure ; fauces at first but moderately injected. On 
the following day, the third of his sickness, with a temperature of 104.5°, 
the efflorescence became a dark red, numerous small extravasations of blood 
had occurred under the skin, the urine contained blood, and finally it seemed 
to consist almost entirely of dark blood ; a large effusion of blood under the 
entire conjunctiva of either eye prevented closure of the eyelids, and probably 
hemorrhages had occurred within the eyes, as the sight was nearly lost. Death 
took place on the following day. In Hebra's article on smallpox is the descrip- 
tion of precisely such cases, but the death of my patient was too early for 
exact diagnosis. 

Varioloid. — The course of varioloid is similar to that of variola, but it is 
somewhat shorter. It commences with rigors, followed by fever, headache, 
pain in the back, vomiting, drowsiness, and sometimes delirium, or even con- 
vulsions. The symptoms in the stage of invasion are, indeed, the same in 
character, and often nearly as severe as in variola. With the initial symp- 
toms there is also sometimes a scarlatiniform eruption, so that the disease 
may at first be mistaken for scarlatina. On the third or fourth day the vario- 
lous eruption commences. The number of pocks is commonly few, often not 
more than twelve to twenty. In the mildest form of varioloid, if the phy- 
sician be not summoned in the stage of invasion, he may not be called at all, 
so that the patient passes through the disease in ignorance of its nature. The 
true character of the malady is not ascertained till others are affected either 
with variola or varioloid. 

The eruption pursues a more rapid course in varioloid than in the unmod- 
ified disease. By the fifth or sixth day the pustules are fully developed, 
though often smaller and less likely to be ruptured than in variola. Often 
in varioloid the eruption aborts. It remains papular two or three days, and 
then declines, or it may reach the vesicular stage and decline without pustu- 
lation. 

The constitutional symptoms in varioloid abate with the commencement 
of the eruptive stage. The secondary fever is slight or absent. 

Such is the usual mild course of varioloid, but not always. If several 
years have elapsed since the vaccination, its protective power is greatly 
impaired, and varioloid may then exhibit as severe a form as ordinary small- 
pox. In some instances it is fatal. 

The term varioloid is, as has been stated, applied to cases of variolous 
disease if there have been previous vaccination. It is also applied by writers 
to second attacks, whether the first occurred from infection or from variolous 
inoculation, but such cases are rare. 

Mode of Death. — Death in smallpox occurs in several different ways. 
The most fatal period is the pustular. Feeble children not infrequently die 
from exhaustion at or about the time that the pustules attain their greatest 



VARIOLA— VARIOL OID. 311 

size. The eruption appears and becomes developed as usual, but there are 
evidences of weakness in the patient, and suddenly the progress of the vesicle 
or pustule ceases. It begins to subside and its walls shrivel. There is evi- 
dently absorption, in part, of the liquid contents. These phenomena are of 
the gravest character. Death is the common result, and within twenty-four 
hours. In other cases death occurs from apnoea. The pock, increasing in 
size in the larynx and trachea, obstructs inspiration, or there may be the 
formation of a pseudo-membrane, as in true croup. This is not an unusual 
mode of death in young children, in whom the calibre of the larynx and 
trachea is small. Sometimes convulsions and coma occur in the last hours 
of life. In other cases the stage of desquamation is reached, but convales- 
cence does not occur. The patient each day becomes more anaemic and 
feeble, and finally death results from failure of the vital powers. Again, 
after smallpox has run its course purpura hemorrhagica may be developed. 
Hemorrhages occur from the gums, throat, nostrils. Blood is vomited, and 
evacuated in the stools. I have known death to occur in all these ways, but 
that from purpura is least frequent. Sometimes, as in scarlet fever, death 
occurs suddenly and unexpectedly in confluent, and even in discrete, variola, 
when the previous symptoms had apparently been favorable. The patient is 
overpowered by the intensity of the virus. 

Anatomical Characters. — In those who have died of variola without 
inflammatory or other complication the heart-clots have been found small, 
dark, and soft. The blood is dark and thin. The vessels of the brain and 
its membranes are injected, so that numerous red points appear on the cut 
surface of this organ. The vessels of the lungs and the abdominal organs 
are congested, while the muscles present a deep-red color. The variolous 
eruption penetrates more deeply than that of any other exanthematic fever. 
It has been stated elsewhere that it occurs not only on the skin, but often 
on the surface of the mouth, fauces, and air-passages. The mucous mem- 
brane in these situations is frequently also the seat of catarrhal inflammation, 
being thickened and softened, and in some parts, as the larynx, a pseudo- 
membrane is occasionally produced, as in croup. 

The eruption very seldom, perhaps never, appears upon the gastro-intes- 
tinal surface, but the solitary follicles and patches of Peyer are often 
enlarged, as in some other zymotic affections. The liver, spleen, and kidneys 
are commonly congested in those who have died of variola. The spleen 
especially is increased in volume and softened ; the kidneys are enlarged, as 
from commencing nephritis, and sometimes softened. 

The minute structure of the pock is described by Rilliet and Barthez and 
others. The vesicle is multilocular, consisting of at least five or six compart- 
ments with distinct partitions. Its centre is united by fibrous bands to the 
derm beneath, which union gives rise to the umbilicated appearance. The 
giving way of these minute bands in the pustular stage occurs when the form 
changes from the umbilicated to the convex. In the pustular stage also, 
according to some, a fibrous formation occurs within the pustule ; according 
to others, this substance is of the nature of the epidermis, presenting the 
appearance of the cuticle when macerated. Mixed with this epidermic or 
fibrinous formation are pus-cells. 

Complications. — There are several different complications of variola. 
One is salivation. This is common in the adult, but rare in the child. 
When it occurs in the child it is slight, commencing with or about the time 
of the eruption, and disappearing in from one to four or five days. Oph- 
thalmia is another complication. Simple conjunctivitis, often quite intense, 
may occur in consequence of pustules developed under the lids. This inflam- 
mation subsides without injury to the eye as the primary disease abates. A 



312 CONSTITUTIONAL DISEASES. 

more serious inflammation occurs at an advanced stage of variola, commen- 
cing in or near the desquamative period. This produces more or less chemosis, 
and sometimes opacity or ulceration of the cornea. A similar inflammation 
may occur in the ear, giving rise to otorrhoea, and even, in some patients, to 
rupture of the drum of the ear. Abscesses in the subcutaneous connective 
tissue have been occasionally observed, especially in the confluent form. 
Subcutaneous infiltration and feebleness of constitution favor their occur- 
rence. Suppuration within the joints is a somewhat rare complication or 
sequel, rendering convalescence protracted, if, indeed, the case be not fatal. 

M. Beraud has published a memoir to show that orchitis in the male and 
ovaritis in the female may complicate variola. These inflammations are 
believed to be accompanied by a small and imperfect variolous eruption 
upon the tunica vaginalis and the peritoneal covering of the ovary. Trous- 
seau states that he has often met this complication in the male since his 
attention was called to it. It is mild, and subsides with the disappearance 
of the eruption. Laryngitis, simple or diphtheritic, bronchitis, pneumonia, 
pharyngitis, purpuric hemorrhages, gangrene of the mouth or other parts, 
oedema pulmonum, and oedema glottidis are occasional complications, some 
of which are frequent, others rare. 

Prognosis. — This depends on the age, vigor of system, form of the 
disease, and the presence or absence of complications. The younger the 
child the greater the danger. Trousseau says : " Confluent variola, and even 
discrete variola, are almost always fatal in individuals less than two years 
old." Above the age of three or four years discrete variola usually ends 
favorably, but the confluent form is still, as a rule, fatal. Varioloid in the 
child is a mild disease, terminating favorably in a large proportion of cases. 
It is milder at this age than in the adult, on account of the more recent 
period of vaccination. If varioloid be severe and the eruption abundant 
in a child who has been vaccinated, it is probable that the vaccination was 
spurious. 

It is not necessary, from what has been said, to specify the favorable 
prognostic signs. The unfavorable prognostics are — great violence of the 
initial symptoms ; early appearance of the eruption ; an abundant eruption, 
especially if pale and without swelling of the surface ; rapid decline of the 
eruption in the vesicular or pustular stage ; hemorrhagic eruption or hemor- 
rhages from the surfaces ; fever continuing after the appearance of the erup- 
tion ; diarrhoea persisting beyond the third or fourth day; delirium or great 
drowsiness; a frequent and feeble pulse; and, finally, obstructed respiration 
— if slow, indicating a pseudo-membrane or variolous eruption in the larynx 
or trachea ; if rapid, indicating bronchitis or pneumonia. 

Diagnosis. — The diagnosis cannot be made with certainty prior to the 
eruptive stage. If, however, smallpox be prevalent, if the patient have not 
been vaccinated, and the symptoms which pertain to the period of invasion 
be present, as headache, pain in small of back, repeated vomiting, drowsiness, 
and perhaps convulsions, there is ground for the gravest suspicion. If in 
addition to these symptoms reddish points begin to appear on the second or 
third day, the diagnosis may be made with confidence. At this early period, 
even before there is any distinct cutaneous eruption, ash-colored spots may 
sometimes be observed on the buccal or faucial surface, the commencement 
of the variolous eruption ; these possess considerable diagnostic value. 

The scarlatiniform efflorescence in the first stage of variola sometimes 
leads to the belief that the disease is scarlet fever. The absence of the 
pharyngitis and the appearance of the variolous eruption soon after the 
efflorescence correct the diagnosis. Smallpox has, in the beginning of the 
eruptive period, sometimes been mistaken for measles. The points involved 



VARIOLA— VABIOL OID. 



313 



in the differential diagnosis have been presented in treating of that disease. 
After the development of the eruption it may be mistaken for varicella. The 
eruption of varicella is, however, preceded by symptoms which are milder 
and of shorter duration, and its appearance is different. It is irregular, 
instead of round, is not umbilicated. and it does not have the round, inflamed, 

Fig. 42. 





W V 



\ I 



\k, 



m 



Variola : first and second days of the eruption. 
Fig. 43. 




A 







Variola : fifth day of the eruption. 
Fig. 44. 




v^;«^> 



Variola : eleventh day of the eruption. 

and indurated base which characterizes the variolous eruption. The erup- 
tion of ecthyma is sometimes umbilicated, but the symptoms of ecthyma 
and variola and the progress of the eruptions in the two diseases are very 
different. 

There is no disease in which it is more imperatively the duty to make an 
early and correct diagnosis than in variola and its modified form, varioloid. 



314 CONSTITUTIONAL DISEASES. 

Smallpox seldom occurs in the eastern part of the United States, notwith- 
standing the very great immigration. Therefore when it does occur and comes 
under observation it is more likely to be overlooked or wrongly diagnosticated 
than if it were more common. Thus in a prominent medical college the mis- 
take was recently made of not diagnosticating varioloid, and several of the 
physicians not fully protected suffered the consequence of infection by this 
loathsome disease, and, while others received cicatrices for life, one died. I 
trust that no one who examines the illustrations kindly furnished me by 
N. E. Vaccine Co. will ever make such a sad error. 

Treatment. — Smallpox, like the other essential fevers, is self-limited, 
and therefore the constitutional treatment should be sustaining and pallia- 
tive. In the first stages of the disease the diet should be simple ; gentle 
laxatives and refrigerant drinks are required if there be much febrile excite- 
ment. Lemonade is a grateful drink, and may be given in moderate quantity. 
Spiritus mindereri in carbonic-acid water may be allowed. As the disease 
advances more nutritious food should be recommended, and in severe cases 
carbonate of ammonium, and even alcoholic stimulants, are required. 

As confluent smallpox is nearly always, and the discrete form often, fatal 
in infancy, the physician should carefully watch the progress of the case in 
the infant. By judicious treatment some in this period of life may be saved 
who otherwise would perish. In the infant depressing measures should be 
avoided. A laxative may be given at first if there be much fever and the 
bowels are constipated ; but the diet should be nutritious, and many soon 
require tonics and stimulants. If the pulse become more frequent and 
feeble, or if, with frequency of the pulse, the face and extremities become 
cool, or in the vesicular or pustular stage the eruption suddenly subside, 
alcoholic stimulants must be immediately employed or the patient dies. 

Such is an outline of the constitutional treatment required in smallpox. 
Sydenham inculcated a mode of treatment which experience has shown to 
be injurious in infancy and childhood. He had observed that the severity 
of the disease was ordinarily proportionate to the amount of eruption, and 
concluded from this fact that measures which retarded the development of 
the eruption were salutary : cold drinks, a cold apartment, scanty covering 
of the body, cathartics that caused derivation of the blood from the surface, 
even sometimes the abstraction of blood, were considered, according to Syden- 
ham's theory, to be useful as means of preventing full development of the 
eruption. 

Sydenham's treatment, however appropriate it might sometimes be in the 
case of robust adults, is unsuitable for children, because they do not, as a rule, 
tolerate in this disease measures which reduce the strength. Moreover, small- 
pox is rendered more dangerous by what Rilliet and Barthez designate per- 
turbating treatment — treatment which renders it abnormal. The regular 
appearance and development of the eruption are requisite in order that the 
case may progress favorably. On the other hand, the opposite plan of treat- 
ment, which families, if left to themselves, frequently adopt — to wit, the 
employment of measures to promote perspiration, as hot drinks and confine- 
ment in a heated room — is also injurious. 

The patient should be kept in a temperature such as he has been accus- 
tomed to and such as is agreeable to him — a temperature at 66° to 70° ; his 
diet should be simple and nutritious ; laxative medicine should only be given 
to procure the natural evacuations. In smallpox, as in all infectious diseases, 
free ventilation of the apartment is required. The room should be dark, for 
a strong light perhaps increases the pitting. 

While the general eruption should not, as a rule, be interfered with, it is 
proper to endeavor to diminish, so far as possible, the size of the pocks on 



VARIOLA— VARIOLOID. 315 

parts exposed to view, so as to prevent disfigurement. Professor Flint, in his 
Treatise on the Practice of Medicine, has published an excellent summary of 
the various measures which have been recommended for accomplishing this 
end. First : The opening and breaking up of the vesicle by means of a fine 
needle. This is tedious practice in confluent variola, but it can readily be 
performed in the discrete form — at least as regards the vesicles upon the face. 
This treatment was proposed by Rayer, and it is recommended by many who 
have tried it. Secondly : After the evacuation of the liquid the cauterization 
of the vesicle by a pointed stick of nitrate of silver. Rilliet and Barthez 
say, in reference to this mode of treatment, " Individual cauterization of the 
pustules is, on the other hand, an almost infallible means of causing them to 
abort. To be successful, it is necessary to penetrate into the interior of the 
pustule with a pointed crayon of nitrate of silver in order to cauterize the 
derm .... It is only the first or second day of the eruption that it (cau- 
terization) has certain success ; nevertheless, we have often seen it succeed 
the third or the fourth day, or even the fifth." Thirdly : The application of 
tincture of iodine once or twice daily over the eruption when in the papular 
stage. Some writers who have employed iodine state that it does not prevent 
pitting, but diminishes it. Its favorable effects are produced by coagulating 
the contents of the papule. Fourthly : The exclusion of light and air by 
means of a plaster. A mixture containing tannate of iron has been employed 
for this purpose in one of our hospitals. This produces a black mask. Light 
and air may be excluded by smearing the face with sweet oil and dusting 
twice daily upon the oiled surface a powder containing equal parts of sub- 
nitrate of bismuth and prepared chalk. Fifthly : The application of mild 
mercurial ointment upon the face or other parts of the surface where it is 
desirable to render the eruption abortive. This mode of treatment does 
diminish the size of the vesicles and the pitting, but I should not recom- 
mend it for children. I have known in the adult severe mercurialization 
from its employment for four or five days, and, though young children do 
not exhibit so readily the effects of mercury, the use of the ointment, unless 
for a very limited period, increases, in my opinion, their feebleness and dimin- 
ishes the chance of their recovery. Calamine made into a paste with sweet 
oil is said to be equally effectual with mercurial ointment, and it produces no 
constitutional effect. Its effect is obviously similar to that of bismuth and 
chalk employed with sweet oil as stated above. Also, I have employed pul- 
verized charcoal made into a thin paste with sweet oil or glycerin, and 
applied daily or twice daily to the face. It effectually excludes the light, 
and the result appeared to be good as regards pitting, but it is a disagreeable 
application. Curschmann recommends as preferable to any of these methods 
the use of iced compresses to the face and hands. The pain, redness, and 
swelling are diminished by their use, but without change in the copiousness 
of the eruption (Ziemssens Encyclop.). If fissures or excoriations occur, an 
application may be made of oxide or carbonate of zinc in glycerin, one drachm 
to the ounce. 

Dr. Tomkyns of the Fever Hospital, Manchester, England, states that he 
has used with good results the following mixture, applied from time to time 
over the surface : 

R. Glycerini, ^ss ; 

Tine, iodini, sjij ; 

Mucil. amyli, Oss. — Misce. 

The intense itching and the fetid odor are, according to my observations, 
best relieved by frequent bathing with the following wash : 



316 CONSTITUTIONAL DISEASES. 

R. Acidi carbolic, ,^j ; 

Tine, camphor., ^ij ; 

Aqua?, Oj. — Misce. 
Shake bottle before using. 

The prevention of smallpox, so far as practicable, is one of the important 
incidental duties of the physician. Isolation of the patient and precautions 
in reference to his clothes and bedding are imperatively required, so great is 
the contagiousness of this disease. The only certain means of prevention is 
vaccination, and providentially the incubative period of the vaccine disease 
is less than that of variola. Therefore, smallpox may be prevented after the 
virus is received in the system by timely and successful vaccination. Vac- 
cination, at any period between the time of exposure and the commencement 
of the symptoms of invasion, will either prevent the occurrence of smallpox 
or modify it. If the symptoms of invasion have already commenced, it is 
uncertain whether it produces any modifying effect. 

Variola is so very contagious that there is danger that the physician and 
attendants may communicate it through their persons or clothing. The virus 
adheres tenaciously to objects, and may be conveyed by them long distances. 
Therefore the room occupied by the patient should contain no unnecessary 
articles, as books or writing material, and the physician attending a case 
should bathe and change his clothing before going elsewhere. A disinfectant 
should also be constantly used in the room, as the following, which I have 
recommended in the treatment of diphtheria and scarlet fever : 

R. 01. eucalypti, 

Acidi carbolic, da. Jfj ; 

Spts. terebinth., ,^ v iij- — Misce. 

Two teaspoonfuls in a quart of water, placed in a tin vessel, shallow and with 
broad surface, and maintained in a state of constant simmering. 



CHAPTER V. 

VACCINIA. 

Vaccinia is a mild eruptive disease which occasionally occurs among 
cattle and has been propagated from them to man. It is characterized by 
the appearance upon the surface of one or more papules, which soon become 
vesicular and then pustular. It is communicable by contact, but, unlike the 
other eruptive fevers, it is not contagious through the air. It is inoculable, 
both by the liquid contained in the vesicle, which is designated vaccine lymph, 
and by the scab which results from the desiccation of the pustule. 

To Gloucestershire, England, the honor belongs of discovering and utiliz- 
ing the fact that vaccinia, a mild and comparatively harmless disease, is trans- 
missible from the cow to man, and that it affords protection from smallpox. 
It appears that a vague opinion prevailed among the farmers of this dairying 
section that a disease which has since been designated vaccinia was occasion- 
ally received from the cow in milking, the virus passing from a pustule on 
the teat to a sore or chap on the hand of the milker, and that those who thus 
contracted the disease received immunity from smallpox. As usually happens 
with important discoveries, so slow of apprehension is the human intellect, 
these people, to whom Providence had revealed a most important fact, were 



VACCINIA. 317 

blind to its real value. Finally, in the year 1724, Benjamin Jesty, whom the 
world has not sufficiently honored, " an honest and upright man," according 
to his epitaph, a farmer of Gloucestershire, had the courage to vaccinate his 
wife and two children. His excellent moral character did not shield him. 
He was regarded by his neighbors as an inhuman brute, who had performed 
an experiment on his own family the tendency of which might be to trans- 
form them into beasts with horns. 

This first essay in vaccination appears to have been entirely successful, but 
the prejudice against the operation continued. A fifth of a century passed, 
during which there was no extension of the benefits of this great discovery. 
At last, toward the close of the last century, Dr. Edward Jenner, a physician 
of Gloucestershire, an inoculator of his district, began to investigate this dis- 
ease of the cow, about which little was known, and the grounds for the belief 
that it afforded protection from smallpox. Fortunately for the world, Jenner 
had been educated under John Hunter, and had learned from his great mas- 
ter to study nature rather than books — to be guided by experience and obser- 
vation rather than by the dogmas of his predecessors or of the schools. 

Jenner performed his first vaccination on the 11th of May, 1796, twenty- 
two years after Benjamin Jesty had lost his good name among his neighbors 
by vaccinating his own family. The popularizing of vaccination, mainly 
through Jenner's perseverance, affords one of the most interesting and in- 
structive chapters in the discovery of medical science — how he went to London 
full of the importance of the discovery, and was there advised by his medical 
friends to desist from his wild schemes, lest he should injure the reputation 
which he had gained from a creditable paper on the habits of the cuckoo ; 
how he was finally allowed to vaccinate in hospital wards, and gained some 
adherents to the new faith among the leading physicians of the metropolis ; 
and, finally, how, as the claims of vaccination began to be recognized at the 
close of the last century and commencement of the present, a most acrimo- 
nious discussion arose which filled all the medical journals of that period. 
The opponents of vaccination resorted to every device to prevent the accept- 
ance of Jenner's views. They attempted to prejudice the people against 
them by specious arguments, by ridicule, and even by caricatures. One of 
the leading journals contained the picture of a cow covered with sores and 
devouring children, and it was urged that vaccination was a bestial operation, 
degrading man to the level of the brute. But the truth had gained a firm 
hold and the practice of vaccination extended. 

The discovery of vaccinia and of its protective power cannot be too highly 
appreciated. It has probably done more to relieve human suffering than any 
other discovery of the last one hundred years, unless we except that of anes- 
thetics, and more to save human life than any other instrumentality of a 
purely physical kind. 

The fact was established in the time of Jenner that the virus of small- 
pox inoculated in the cow produces vaccinia, which in its propagation back 
to man never returns to its original form, but always remains vaccinia. 
Moreover, Jenner believed that the disease known in the horse as the grease 
was identical in nature with vaccinia in the cow. He failed, however, in his 
experiment to communicate vaccinia from the horse, but other experiments 
have been more successful. In 1801 a Dr. Loy of the county of York, Eng- 
land, met two cases of vaccinia in persons who had taken care of a horse 
affected with the grease, and from the lymph which he obtained was able to 
produce vaccinia in the cow. In 1805, Viborg, a Danish veterinary surgeon. 
after many failures, succeeded also in communicating vaccinia to the cow by 
means of the virus taken from a horse. 

From this time little light was thrown on this subject till within the last 



318 CONSTITUTIONAL DISEASES. 

twenty, years. Although Loy and Viborg, and perhaps a few others, had 
recorded their success, other experimenters had failed to communicate vac- 
cinia from the horse. In the absence of additional cases the profession began 
to question whether there might not have been some error in the observations 
of the gentlemen whose names I have mentioned, and whether a disease iden- 
tical with vaccinia, or a disease which may communicate vaccinia to the cow 
or to man, occurs in the horse. 

Observations confirmatory of those of Loy and Viborg were at length, 
however, made, which must be regarded as conclusive. In 1856. in the 
department of L'Eure-et-Loir, France, M. Pichot was consulted by a boy 
who had on the back of his hands vaccine pustules which had apparently 
reached the eighth or ninth day. He had not taken care of nor been in con- 
tact with a cow, but had a few days before taken care of a horse affected with 
the grease. Vaccination was performed by means of the lymph taken from the 
pustules, and genuine vaccinia was produced. 

Again, in 1860 an epidemic prevailed among the horses in Kiemes and 
Toulouse, France. A mare sickened with the disease, and there was swelling 
of the hough, with discharge of sanious matter. M. Delafosse vaccinated two 
cows with this matter and communicated genuine vaccinia. This epidemic 
was believed by the veterinary surgeons to be an eruptive fever, differing in 
its nature somewhat from the disease or diseases which have ordinarily been 
designated the grease. It has been conjectured that two or more distinct 
affections of the horse have the same appellation — one of which, it is now 
admitted, is identical with vaccinia of the cow and may communicate it ; and 
the reason why so many experimenters have failed to vaccinate the cow from 
the horse is that they have used the virus of the wrong disease, or have taken 
virus from horses which had been affected with the true disease, but from 
ulcers which had lost their specific character. 

Prior to the time of Jenner variolous inoculation was practised in most 
civilized countries, since variola produced in this way was found to be milder 
than when arising from infection. This practice is now obsolete, forbidden 
in some places by legislative enactments. It is superseded by vaccination. 
Vaccination, or the introduction of vaccine lymph into the system, is quickly 
and conveniently performed by scarifying with a lancet and rubbing into the 
incisions the lymph or a little of the scab pulverized and dissolved in a drop 
of cold water. It may also be performed by scraping off the epidermis with 
the edge of the instrument till the blood begins to ooze ; and also, though 
with less certainty of success, by puncturing the skin with the point of the 
lancet or by an instrument called the vaccinator. The scab should never be 
employed when it is possible to obtain pure lymph, since it contains animal 
matter apart from the virus, and may be the medium through which other 
diseases may be communicated. Besides, it is much less active than pure 
lymph. 

If the child have a vascular nsevus, this may be selected as the point of 
vaccination. Unless of large size, it can usually be cured by the inflamma- 
tion which vaccinia produces. Statistics collected by Simon, as well as 
Marson, show that in those who contract varioloid the larger the number 
of vaccine cicatrices the milder the disease and the less the proportionate 
number of deaths. In Simon's statistics of those who stated that they had 
been vaccinated, but who presented no cicatrix, 21f per cent, died ; of those 
who had one cicatrix, 71 per cent, died ; of those who had two, 4^ per cent, 
died ; of those who had three, If per cent, died ; while of those who had four 
or more cicatrices, only f per cent. died. These statistics would seem to indi- 
cate the propriety of vaccinating in several places. But. so far as appears, 
when two or more cicatrices were observed the patients may have been vac- 



VACCINIA. 319 

ciliated at different times, at intervals of several years ; and if so the inference 
would not follow that more complete protection is produced by vaccinating 
in several places than in one. Moreover, if vaccination be performed in the 
usual manner by several incisions on the arm, and the virus be fresh and 
active, usually two or more distinct vesicles arise, which unite in their devel- 
opment and probably protect the system as much as if they were separated 
by a wider space. 

Appearances ; Symptoms. — In genuine vaccination no effect is observed, 
except the slight inflammation due to the operation, till the close of the third 
day. Then the specific inflammation commences. This is indicated by a small 
red point, at first scarcely visible, indurated and slightly elevated, as deter- 
mined by the touch rather than by the eye. This increases, and on the fifth 
day the cuticle over the inflamed part begins to be raised by a transparent and 
thin liquid. The vesicle increases in diameter, and by the sixth day presents 
an umbilicated appearance and is surrounded by a faint and narrow red zone. 
At the close of the eighth day the vesicle is fully developed. Its size varies 
considerably. It is usually from a sixth to a third of an inch in diameter, and 
oval or circular. If the vaccination have been performed by incisions, the size 
of the matured vesicle may be considerably larger and its shape irregular, in 
consequence of the union of two or more vesicles. The eruption now presents 
a whitish or pearl-colored appearance, due to the whiteness of the cuticle and 
the transparence of the liquid underneath. If the vaccination be performed 
by incisions, it is not unusual to observe over the centre of the vesicle, and 
adhering to it, a small yellowish scab, which has resulted from the scarifica- 
tion and which contains none of the virus. 

The vaccine vesicle, like that of variola, consists of compartments, com- 
monly eight or ten, with complete partitions, so that there is no intercom- 
munication. On the ninth day the inflamed areola becomes more distinct 
and its diameter rapidly increases. Its color is deep red, its temperature is 
considerably elevated, and it is accompanied by more or less induration of the 
subcutaneous tissue, and it is tender to the touch. On the tenth day the pock 
has reached its full development. The areola extends from one to two inches 
away from the vesicle, becoming fainter at its outer circumference and grad- 
ually disappearing in the healthy skin. The shape of the outer circumference 
of the areola is irregular, projecting farther at one point than another, though 
its general form is circular. 

On the tenth day, when the inflammation has reached its maximum, the 
heat, itching, and tenderness in and around the pock are such that the child 
is often feverish and restless. Occasionally the glands of the axilla become 
swollen and tender. In other cases, in which there is but a moderate amount 
of inflammation, the constitutional disturbance is slight. 

At the close of the tenth day or on the eleventh the inflammation begins 
to decline ; the areola becomes narrower and then disappears ; the induration 
and tenderness abate ; and with this change the pustule desiccates, its liquid 
is absorbed, and there results a brownish or dark mahogany-colored scab, 
which is detached, ordinarily, between the fourteenth and twenty-first days. 
The cicatrix, at first reddish like all recent cicatrices, gradually becomes paler. 
and remains whiter than the surrounding integument. It presents several 
minute depressions or pits, which indicate the genuineness of the vaccination. 

The theory that smallpox becomes vaccinia by passing through the heifer, 
as we have given it above, has for many years been undisputed. But recently 
the theory has been promulgated that vaccinia and variola, instead of being- 
forms of the same disease, are essentially distinct — that when the heifer 
is inoculated with the virus of smallpox, the disease which is produced is 
a modified smallpox, but not vaccinia, which occurs as a spontaneous disease 



320 CONSTITUTIONAL DISEASES. 

among cattle. It may be that the old theory, which no one doubted until 
recently, is wrong, but that vaccination prevents smallpox just as a mild 
attack of scarlet fever prevents a severe attack of the same disease, shows, 
in my opinion, a close relationship between vaccinia and the severe malady 
which it prevents. We wait for more conclusive facts in support of the 
new theory before accepting it. 

Anomalies, Complications, and Sequels. — The vesicle is often broken 
accidentally or by the nails of the child. If the top of the vesicle be destroyed 
or most of the compartments be opened, the inflammation is commonly in- 
creased, considerable suppuration occurs, and there results a large, irregular, 
yellowish scab consisting of the virus mixed with desiccated pus. The scab 
is entirely unreliable and unfit for the purpose of vaccination, though the 
protective power of the disease is not diminished by injury of the vesicle 
even if it be totally destroyed. The cicatrix which results from extensive 
injury to the vesicle is usually large and without the indented points which 
characterize the normal cicatrix. 

In rare cases, when the inflammation which surrounds the vesicle is 
intense and deep-seated, suppuration occurs in the subjacent connective 
tissue, giving rise to an abscess. This abscess is commonly of small size, 
but it increases the fretfulness and constitutional disturbance which attend 
vaccinia. This subcutaneous suppuration occurs most frequently in those 
who have a scrofulous or vitiated state of system. Inflammation of the 
lymphatic glands of the axilla I have spoken of as not infrequent in vaccinia. 
This sometimes proceeds to suppuration, producing an unpleasant though not 
serious complication. 

It sometimes happens that vesicles appear in other parts besides the points 
where the virus was inserted. These supernumerary vesicles commonly occur 
where the cuticle has been removed by scalds or injuries. 

Trousseau relates the case of an infant whom he had vaccinated. On the 
eleventh day he was astonished to find twenty-seven vaccine pustules on the 
face, trunk, and limbs. This infant had, however, before the vaccination a 
simple non-specific eruption over the whole body, and it was believed that it 
had produced these vaccinations by transferring the lymph with its nails to 
the various parts where the cuticle was denuded. 

It is not unusual, also, to observe minute papules appearing on parts of 
the surface simultaneously with or soon after the vesicle, and in a few days 
declining. These seem to be abortive vaccine eruptions. 

One of the most serious complications is erysipelas. This may occur 
directly from the operation or from the inflammation caused by the vesicle 
when the virus possesses no deleterious property ; and, again, it may result 
from some unknown element in the virus. It may occur immediately after 
the operation, when it commonly prevents the working of the virus, or during 
the vesicular or pustular stage, or, again, after desiccation and separation of 
the scab. I have observed it at all these periods. 

Erysipelas, occurring as a complication of vaccinia, is invariably referred 
by the friends to the virus employed, and the physician who has had the mis- 
fortune to vaccinate is often unjustly blamed. In many of these cases there 
is a strong predisposition to erysipelas at the time of the vaccination, and 
the operation or the inflammation which accompanies the normal develop- 
ment of the vesicle serves simply as an exciting cause. Erysipelas would 
occur as soon from a non-specific sore ; indeed, we not infrequently are called 
to cases of this disease In young children which commence from non-specific 
sores upon the genitals or on one of the limbs. That the fault is not in the 
virus employed is evident from the fact that other children, vaccinated with 
the same, have simple uncomplicated vaccinia. 



VACCINIA. 



321 



Septicemia is a very serious complication of vaccinia. On one occasion 
since the publication of the last edition, 450 infants were vaccinated in the 
Foundling Asylum. This institution being under the charge of a large sister- 
hood, all the inmates are clean, and all the 450 did well with one exception. 
This infant, in its second year, is believed by the physicians who examined it 
to have poisoned the vaccine sore by scratching it with dirty finger nails. It 
had sores and a dusky red discoloration of parts of the surface, and a deep 
ulcer over its right leg denuding the tibia nearly half its length. We were 
taught the important lesson which surgeons practise, of disinfecting the skin 
before the operation and to protect it subsequently by some dressing. 

Sometimes, on the other hand, the cause of erysipelas, whatever it may 
be, exists in the virus. (For further facts in reference to this subject the 
reader is referred to our remarks on erysipelas.) 

The fact is established by many observations that syphilis is communi- 
cable by vaccination. The symptoms of it may not appear till vaccinia has 
terminated or for a little time subsequently, but it then constitutes a very 
serious sequel. A physician of this city, well known in this community as 
skilful in the diagnosis and treatment of skin diseases, and therefore not 

Fig. 45. 










BPSi^ 



Vaccine vesicles. Normal shape and size on tenth day. 

likely to be mistaken as regards the nature of the diseases, states that he 
communicated syphilis to two infants by vaccinating with the same scab. 
Both had the characteristic syphilitic eruption. In January, 1868, an infant 
21 



322 COXSTITUTIOXAL DISEASES. 

was brought to Prof. Alonzo Clark's clinic in this city having syphilitic rupia, 
which in the opinion of the physicians present was undoubtedly the result 
of vaccination. 

Trousseau relates the case of a young woman eighteen years old who was 
vaccinated with virus taken from an infant apparently in perfect health. The 
vaccination was unsuccessful, but twenty-three days subsequently his atten- 
tion was called to an eruption which had appeared in two places on the woman's 
arm corresponding with the points where the virus had been inserted. The 
eruption was that of ecthyma, which by the next examination, which was 
five days subsequently, had been transformed into rupia. The axillary lym- 
phatic glands were tumefied and indolent : finally roseola appeared, which 
removed all doubts as to the syphilitic character of the disease. There was 
syphilitic infection, which first manifested itself in the points where vaccina- 
tion had been performed (Article de la Vaccine'). It is not ascertained in 
Professor Clark's case, nor is it stated in Trousseau's, whether the lymph or 
scab was employed for vaccination. There can be little doubt that the pure 
lymph never communicates anything but vaccinia, and if by vaccination any 
other disease be imparted, a little blood has mingled with the lymph or the 
scab has been employed. 

The vesicle in genuine vaccinia is sometimes very small, not having a 
diameter of more than two lines. Occasionally the development of the 
vesicle is retarded. It does not appear till two or three days later than the 
usual time, or even a longer period. 

Vaccinia is modified by certain diseases. It is arrested by measles and 
scarlet fever, pursuing its course after the subsidence of the exanthem. On 
the other hand, it sometimes modifies the paroxysmal cough of pertussis, but 
only during the time when the pock is maturing. Eczematous eruptions 
occasionally occur after vaccinia, as they often do after the other eruptive 
fevers, or if already present they may be aggravated. 

Subsequent Vaccinations. 

A second vaccination, performed prior to the ninth day after the first 
vaccination, is successful. A genuine vaccine eruption results, which is 
smaller the more advanced the primary disease. This second eruption over- 
takes the first. On the ninth day the susceptibility to vaccinia is, in most 
cases, lost, so that vaccination performed on the tenth or subsequent days 
is unsuccessful. 

As a rule, an acute contagious disease occurs only once in the same 
individual. Vaccinia is an exception. In most people, after a few years it 
can be produced a second time, and cases of a third or fourth successful 
vaccination at intervals of a few years are not uncommon. Xow, subsequent 
cases of vaccinia differ from the first, which has been described above. The 
period of incubation is shorter, and the vesicular, pustular, and desiccative 
stages succeed each other more rapidly, so that the whole period of the disease 
is less. The variation from the appearance and course of the first vesicle is 
proportionate to the degree of protection which the first vaccination still affords 
both as regards smallpox and vaccinia. If several years have elapsed since 
the first vaccination, and the protective power which it affords is nearly lost, 
the second vaccinia differs but little from the first. If. on the other hand, 
the first vaccination still affords nearly complete protection, the result of the 
second is slight ; the eruption is insignificant, lacking the characteristic appear- 
ance of the vaccine vesicle, resembling a common sore, and disappearing within 
a week. It is not accompanied by the inflamed areola or any appreciable con- 
stitutional disturbance. 



VACCINIA. 323 

Vaccination often produces no result. This is sometimes due to the fact 
that the lymph or scab employed is useless. It has spoiled by keeping or 
never has been good. In other cases it is due to a lack of susceptibility in 
the person. Some take vaccinia with difficulty and only after several vacci- 
nations ; just as children, though fully exposed, often fail to take measles or 
scarlet fever, on account of a condition of the system which prevents the 
reception of the virus or antagonizes and controls its action. In some 
instances after vaccination an eruption is produced which may or may not 
be genuine, but it immediately becomes purulent and is soon broken. A large 
yellow, uneven scab results, having none of the appearance and containing none 
of the vaccine virus. This scab, as well as the liquid matter which preceded 
the formation of the scab, is utterly useless for the purpose of vaccination, 
and if so employed will probably cause a sore from its irritating effect, but 
not of a specific character. If, in place of the true vaccine vesicle, the erup- 
tion presents the appearance which I have described — namely, that of a pus- 
tule, soon breaking and forming a large irregular, yellowish scab — the vaccinia 
(if it be correct so to designate it) must be considered spurious. A sore has 
been produced by the animal matter which was employed in the vaccination 
along with the virus, which has modified the action of the virus, and probably 
has rendered it useless as a means of protection ; or there may have been no 
virus inserted with this animal matter. The physician should in such cases 
insist on a second vaccination. 

Cases like the above are of frequent occurrence, and the parents of the 
child are often satisfied with the result. They see an eruption following vac- 
cination, accompanied by considerable inflammation and leaving a cicatrix. 
Unless undeceived by the physician, they probably remain in the belief of 
the child's security until, perhaps, it takes smallpox. Such cases obviously 
tend to diminish the confidence which the public should have in vaccination 
as a means of protection from smallpox, and on account of their frequent 
occurrence it is important in every case that the physician should see the 
result of his vaccination. It has been proposed, as a means of determining 
the genuineness of vaccinia, to revaccinate when the eruption begins, and 
if the first be genuine the second will overtake it. This is called Brice's test, 
but it is not necessary, since the physician, familiar with the appearance of 
the true vesicle, can determine at once its genuineness by the sight. 

Protection from Vaccination— Re vaccination. 

It was believed by the early advocates of vaccination that the general 
performance of this operation would soon eradicate smallpox from the com- 
munity, so that it would be interesting only to the medical historian as a 
scourge of past ages. This result, however, is only partially achieved. As 
a rule, the greater the benefit of any measure designed to ameliorate the 
condition of mankind, the greater and more numerous are the obstacles which 
diminish its effectiveness. Science is full of examples like this. Fortunately, 
these obstacles as regards vaccination are not such as to impair the confidence 
of physicians in its protective power, and it is not too much to expect that 
this simple operation will yet be the means of rendering smallpox a disease 
almost unknown, unless in its modified form. 

Vaccination should be performed in the first year of life. In rural dis- 
tricts, where there is little danger of exposure to smallpox, it may be deferred 
till the age of ten or twelve months. In the city, on the other hand, where 
there is constant intercourse of people and where contagious diseases are often 
contracted in ignorance of the time and place of exposure, an earlier vaccina- 
tion is advisable. Some physicians recommend performance of the operation 



324 CONSTITUTIONAL DISEASES. 

as early as the age of four or six weeks. The objection to this is that if 
erysipelas occur so young an infant is likely to perish from it, whereas an 
infant three or four months old ordinarily recovers. For this reason I believe 
that the most suitable age is about four months for the city infant in ordinary 
times ; but if smallpox be epidemic, vaccination should be performed at an 
earlier age. I have vaccinated even the new-born infant when smallpox had 
broken out in adjoining apartments. 

Vaccinia usually extinguishes, for a time, the susceptibility to smallpox. 
According to Mr. Gintrac, varioloid does not occur within two years in those 
who have been vaccinated. It may, however, in exceptional instances, occur 
in a mild form within a few months after vaccination. The protection afforded 
by vaccination gradually diminishes by time, but it does not probably, as a 
rule, entirely cease. Varioloid, however, occurring thirty or forty years after 
a successful vaccination is likely to be severe, and it may even be fatal, show- 
ing that it has been but slightly modified. In other cases, even after so long 
an interval, the symptoms present a degree of mildness which indicates that 
the protective power of the vaccination is not entirely lost. 

If a second vaccination be practised soon after the scab from the first vac- 
cination has fallen, it will usually produce no result, but in other cases it gives 
rise to a little redness, swelling, and induration, which show that vaccinia has 
been reproduced, though in a very mild and insignificant form. It is probable 
that in these cases varioloid might also occur by exposure, though with a 
mildness corresponding with that of the vaccinia. The longer the period 
after the first vaccination, the greater the number of those in whom a second 
vaccination is effective, and, as has already been stated, the greater also the 
liability to the variolous disease until the system is protected by a second 
vaccination. A second vaccination should be performed about the sixth or 
eighth year, and a third between the fifteenth and twentieth years. If small- 
pox be epidemic, it is proper to vaccinate all who have not been vaccinated 
within three or four years. 

Selection of Virus. 

The lymph is preferable to the scab for vaccination, provided that it can 
be obtained fresh. The scab is more easily preserved, and therefore, if the 
lymph and the scab be old, the latter is to be preferred. The lymph should 
be taken on the fifth day if the vesicle be sufficiently developed. It may also 
be taken on the sixth, seventh, or even eighth day, provided that the areola 
has not formed. The lymph of the fifth day acts with greater energy, though 
that of the sixth or seventh day is not much inferior. Lymph obtained after 
the formation of the areola is less efficient, though it may communicate the 
genuine disease. 

There is no mode of vaccination so reliable as the use of lymph taken 
directly from the arm and immediately inserted — the arm-to-arm vaccination. 
Lymph can be preserved for a few days on a flattened surface of whalebone 
or the segment of a quill, and if employed within a week it will usually com- 
municate vaccinia. Lymph may be preserved a longer period between two 
surfaces of glass, but the best way of preserving it is in capillary glass tubes. 
The end of the tube is placed within the vesicle, and the lymph ascends by 
capillary attraction. When a sufficient quantity is received, the ends are 
sealed by holding them for a moment in a flame. Care is requisite in doing 
this so as not to heat the lymph, as it is spoiled by a temperature much above 
that of the body. When the lymph is used, the ends of the tube are broken, 
and by blowing gently through it a sufficient quantity is received on the point 
of a lancet. 



VACCINIA. 325 

If the scab be genuine, it presents a dark-brown or mahogany color, and 
has a circular, oval, or at least a rounded form ; it is firm or compact, and has 
a lustre. Soft, yellowish, and irregular scabs are not genuine, and those of a 
dull appearance or without lustre have usually spoiled in the keeping. The 
scab is best preserved in soft beeswax, which excludes the air, and it should 
be kept in a cool place. It is the belief of many that the vaccine virus grad- 
ually becomes weaker by passing successively through the human system 
(Condie. American Journal of the Medical Sciences, April, 1865), and that 
therefore different specimens of virus work with different energy according 
to the degree of removal from the cow. To what extent this view is correct 
is not fully ascertained, but certainly if the virus employed continue to pro- 
duce a small vesicle attended only by a little inflammation, there is reason to 
believe that the protection which it imparts is less than that from virus which 
works with greater energy, and it should be exchanged for such. In New 
York we are able to obtain at any time lymph directly from the heifer. It 
has never passed through human blood, for the original lymph came from 
cattle in one of the provinces of France, where vaccinia was prevailing epi- 
demically. The popular objection to vaccination is obviated by the use of 
this lymph, but it works with great energy, producing a large pock and a 
sore which is often a month in healing. I have found it very reliable, and 
prefer to use it in ordinary cases. 

In the Boston Medical and Surgical Journal of October 12, 1882, appeared 
a sketch of the following remarkable case. It shows a new and unusual phase 
of vaccinia : 

•• The case about to be reported is entirely unique ; the record of a similar 
one I have been unable to find anywhere. Mrs. B., a healthy woman, the 
mother of two children, was vaccinated February 13th, with bovine virus, 
by her family physician, Dr. Harris of Roxbury, through whose kindness I 

Fig. 46. 







Vaccinia communicated by the mother's milk. 

saw the case, and to whom I am indebted for the following notes. On the 
fifth day after vaccination the patient complained of headache, was feverish, 
and in fact had the usual amount of discomfort that attends a successful 
revaccination. Mrs. B. was at this time nursing her infant, a child about 



326 CONSTITUTIONAL DISEASES. 

six months old. The child had not been vaccinated on account of eczema 
from which it was suffering at that time. On March 9th, as nearly as the 
mother can remember, an eruption appeared on the head, thorax, and the 
legs of the child, who had been feverish and irritable for two or three days 
previous. On some portions of the body the eruption was confluent, but on 
the arms and thighs it presented the characteristic appearance of cow-pox. 
It was not an instance of accidental inoculation, for there was no possible 
way by which the child could have introduced the virus at so many different 
points. The disease must have been contracted from the mother through 
the medium of her milk." 



CHAPTER VI. 

VARICELLA. 

Varicella, chickenpox, or swinepox is the shortest and mildest of the 
eruptive fevers. It is highly contagious, so that few children escape who are 
exposed to it. Its period of incubation is from fifteen to seventeen days. 
Hutchinson (Brit. Med. Jo-urn., 1881) and Le Gendre (JDe Concours Med., 1887) 
state that varicella is inoculable, but some years ago inoculations which I 
performed with the lymph of the varicellar vesicle were without result. 
It attacks the same individual but once, and it occurs as an epidemic. It 
has been thought by some to prevail most immediately before, during, or 
after epidemics of smallpox, and it has been conjectured that it is a modified 
form of variola, and hence its name, which signifies little variola. This idea 
is, however, entertained by few, and it is opposed by the following facts: Vari- 
cella may occur after variola or variola after varicella without any modifica- 
tion, and the two diseases are very dissimilar as regards gravity of symptoms 
and duration. The variolous disease, whether smallpox or varioloid, often 
occurs in the adult ; varicella, on the other hand, is a disease of infancy and 
childhood. I have seen one adult case, which I recall to mind, and Professor 
Flint states that he has also observed varicella in the adult, but its occurrence 
at this period of life is rare. Senator relates a case that occurred at the age 
of eleven days. In 584 cases observed by Baader the ages were as follows : 

Cases. Age. 

382 1-5 years. 

191 6-10 " 

7 11-15 " 

2 16-20 " 

2 ...... . 21-40 " 

Moreover, varicella and variola have been known to occur simultaneously in 
the same individual. Such a case was reported by M. Delpech in a memoir 
published in 1845. 

Symptoms. — Varicella usually commences with such symptoms as usher 
in ordinary mild febrile attacks — namely, headache, languor, chilliness, and 
sometimes aching in the back and limbs. Fever supervenes, which is usually 
moderate, the pulse rising perhaps to 100 or 112, and the thermometer show- 
ing an increase of temperature, but less than occurs in the other eruptive 
fevers. These symptoms which precede the eruption are sometimes absent 
or are so mild as to escape notice. The fever usually ceases on the second 



VARICELLA. 327 

day. but it may return on the following night. The appetite is rarely lost, 
and most children continue more or less at their amusements. 

When the above symptoms have continued about twenty-four hours the 
eruption appears first over the trunk, and soon afterward over the face and 
limbs. It consists of minute disseminated papules which become vesicular 
in the course of a few hours. The occurrence of the vesicular stage is nearly 
simultaneous on all parts of the surface, and commonly fresh vesicles appear 
during the first three or four days. The vesicles lack the hard, indurated 
base of the variolous eruption, though they are sometimes surrounded by a 
faint zone of redness. They differ also from the variolous eruption in the 
absence of umbilication and in irregularity of shape. Some are small and 
acuminate, some hemispherical and of medium size, and others oval or elon- 
gated and of large size. The inflammation is quite superficial, not involving 
the subcutaneous tissue and scarcely affecting the deepest layer of the skin. 

The- vesicles vary in size from the diameter of half a line to that of even 
three lines. They occasionally give rise to slight itching. On the second 
day of the eruption or third day of the disease they are still fully developed, 
their liquid contents being nearly transparent. At the close of this day the 
liquid begins to be somewhat cloudy and its absorption commences. On the 
fourth day of the disease desiccation progresses rapidly, and by the fifth the 
liquid has for the most part disappeared, and a scab results, small, thin, and 
of a yellowish-brown color. The scabs are soon detached, the redness which 
indicated their seat disappears, the epiderm which had been raised and 
removed by the eruption is reproduced in its normal state, and in a few days 
all evidence of varicella is effaced. A cicatrix occasionally results, but it is 
due not to the simple varicellar eruption, but to a sore produced from the 
eruption by the scratching of the child. 

The number of vesicles varies considerably in different cases. They are 
never, so far as I have observed, confluent ; but they are sometimes so abun- 
dant in young children that if the disease were variola it would be called 
severe discrete. They occur also on the buccal and faucial surfaces, where 
they soon break, forming small ulcers. . The duration of the disease from 
the first symptoms until the disappearance of the crusts is eight or ten days. 

Mr. J. Hutchinson of London has described a rare form of varicella in 
which the eruption becomes gangrenous. It occurs most frequently in feeble, 
ill-conditioned children, but sometimes in those who are well nourished. Only 
a portion of the vesicles become gangrenous. Where the gangrene occurs a 
deep and unhealthy ulcer forms underneath the scab, which does not heal or 
heals slowly. This rare form of varicella is very fatal, death sometimes 
occurring from pyaemia and secondary abscesses. Crocker states (London 
Lancet, May 30, 1885) that the gangrene sometimes occurs upon a part of 
the surface which is not the seat of the eruption. 

Complications ; Sequels. — Complicating maladies which sometimes 
supervene in varicella do not, for the most part, occur in consequence of this 
disease, but are independent of it. Erysipelas has in rare instances super- 
vened on the varicellar eruption, but its occurrence is attributable to the 
ordinary causes, of this disease, rather than to varicella. Various sequela? 
of varicella have been mentioned by writers, among which we may mention 
'anaemia, pemphigus, urticaria, bronchitis or bronchi-pneumonia (Meigs and 
Pepper), ulcers leading to glandular enlargements and tuberculosis, and 
nephritis (Henoch, Janssen, Oppenheim). 

Diagnosis. — Obviously, the only diseases with which varicella is liable 
to be confounded are such as present vesicles at some stage of their course. 
From the local vesicular eruptions this disease is diagnosticated by the fact 
that the vesicles appear on all parts of the surface. It is sometimes mistaken 



328 CONSTITUTIONAL DISEASES. 

for variola or varioloid, or vice versa — a mistake very damaging to the reputa- 
tion of the physician. The points of differential diagnosis are the symptoms 
of invasion — severe and lasting three or four days in the one, mild and con- 
tinuing only one day in the other ; an eruption passing slowly through its 
stages from the papular to the pustular, umbilicated, with circular, raised 
and inflamed base, appearing first on the face and neck, and not till a day 
later on the legs, in the one disease ; while in the other the evolution, shape, 
and course of the eruption, as described above, are materially different. By 
proper attention to these distinctive features it is rarely difficult to diagnosti- 
cate varicella. 

Prognosis. — In ordinary uncomplicated varicella this disease is always 
favorable. Gangrenous varicella, which is very rarely seen in America, may 
be fatal, and complications may render a case grave. 

Treatment. — On account of the general mildness of varicella, prophy- 
lactic measures, as isolation of the patient, are seldom enforced in America, 
and the disease, when not complicated or gangrenous, requires little treat- 
ment ; but the patient should be quiet and indoor during its continuance. 
Large vesicles upon the face should be punctured early and irritation by 
rubbing should be avoided. Complications and gangrenous varicella require 
appropiate treatment, especially supporting remedies. Anaemia or glandular 
swellings remaining after varicella require tonics, especially cod-liver oil and 
syrup of the iodide of iron. 



CHAPTER VII. 

DIPHTHERIA. 

Diphtheria is one of the most dreaded, one of the most fatal, and 
unfortunately one of the most common, maladies of childhood. It is pro- 
duced by a micro-organism. It is characterized by the occurrence of a 
grayish-white pellicle upon the mucous surface or the skin deprived of its 
protecting epithelium. The specific principle is ordinarily received by the 
inspiration of infected air, but it is sometimes received by direct contact 
of infected matter with one of the surfaces not lying in the respiratory tract. 

Diphtheria is a disease of antiquity. M. Sanne mentions the following 
names by which it has been known in different countries and at different 
periods: Ulcus Syriacum, ulcus iEgyptiacum, garrotillo, morbus suffocans, 
affectus strangulatorius, pestilentis gutturis affecto, pedancho maligna, angina 
maligna, anginosa passio, mal de gorge gangreneux, ulcere gangreneux, angina 
polyposa, angine maligna, croup, diphtheritis, diphtheria. These terms express 
the prominent characteristics of diphtheria. 

It is impossible to state or form a probable conjecture in regard to the 
time when diphtheria originated, but its origin antedated the Christian era. 
According to Aurelianus, Asclepiades, who lived one hundred years before 
Christ, scarified the tonsils and performed laryngotomy for the relief of res- 
piration, and it is supposed that he treated cases of membranous croup, and 
probably diphtheria. Aretseus, a Greek physician of Cappadocia at the com- 
mencement of the Christian era, gives in writings still extant a clear and 
accurate description of mild and severe diphtheria. After describing what he 
designates ulcers upon the tonsils, " covered with a white, livid, or black con- 
crete product," he adds : " If the malady invades the chest by the trachea, it 



DIPHTHERIA. 329 

causes suffocation on the same day. Children up to the age of puberty are 
most exposed to this disease." He gives also a graphic and truthful descrip- 
tion of the suffering of the child when the disease extends to the larynx, and 
croup results. Galen, in the second century of the Christian era, apparently 
alludes to diphtheria when he describes a fatal disease prevalent in his time 
in which fragments of " membranous tunic " are expelled. He states that he 
is able to determine by the manner in which the fragments are expelled, by 
coughing or spitting (hawking), whether they are detached from the larynx 
or the pharynx. Ccelius Aurelianus, a Latin physician who is supposed by 
some to have lived in the second century, and by others as late as the fifth 
century, describes a grave angina in which the symptoms which sometimes 
arise correspond with those in diphtheritic croup and diphtheritic paralysis as 
observed at the present time. In the fifth century Aetius of Amida described 
a disease accompanied by ;i crusty and pestilential ulcers," sometimes having 
a whitish and in other instances an ashy or rusty color, and not preceded by 
a discharge. Aetius alludes to the hoarseness which he says sometimes super- 
venes and is a source of danger up to the seventh day. 

From the close of the fifth century until the sixteenth the record of 
diphtheria is broken. It is probable that during the long period embraced 
in the Dark Ages every decade witnessed epidemics of this fatal malady, 
but if they were observed and recorded the records were lost, the literature 
of diphtheria sharing the fate of general literature during this time of intel- 
lectual darkness. On the revival of learning many epidemics of diphtheria 
were recorded in the medical literature of Europe, and this disease has since 
been a common topic of discussion in the civilized portions of the Eastern 
hemisphere. 

Those who have made special study of diphtheria believe that its first 
occurrence in North America was in New England. It is stated that Samuel 
Danforth of Roxbury, a graduate of Harvard, lost three of his children in 
1659. within two weeks, from a disease which was designated " malady of 
bladders in the windpipe." Again, John Josselyn made two voyages to New 
England in 1638 and 1663, and in his memoranda he states that the English 
in New England " are troubled with a disease in the mouth and throat, which 
hath proved mortal to some in a very short time. This disease is designated 
quinsies and imposthumations of the almonds with great distempers of colds." 
Whether these early New Englanders had diphtheria or not I am unable 
to say, but nearly a century had elapsed from the time of Danforth and 
Josselyn when the much wider and more fatal epidemic, more clearly one of 
diphtheria, occurred. 

On March 20, 1635, at Kingston, a town fifty miles northeast of Boston, 
occurred the first case of the disease, which was destined to overrun the British 
possessions in North America. The first forty attacked by it died ; the first 
patient survived three days ; the three next attacked lived four miles from 
the first patient. When the epidemic reached Boston, Dr. William Douglass 
made a full and accurate clinical examination of it, and wrote a monograph 
containing the result of his observations. Douglass, not knowing that Bos- 
ton was soon to be the " Athens of America," states in his exordium that in 
plantation life neither honor nor credit are to be acquired by writing. His 
sole object in publishing his monograph was to induce others to investigate 
the disease more fully. Death, he states, usually occurred from the fauces 
or neck, which was greatly swollen. J. Dickinson, A. M., of Cambridge, a 
clergyman, published what he designated " Observations on that terrible 
Disease vulgarly called ' Throat Distemper.' " He writes : " Some expecto- 
rated incredible quantities of a tough whitish slough from their lungs 

I have seen several pieces of this crust several inches long, and near an inch 



330 CONSTITUTIONAL DISEASES. 

broad, torn from the lungs by the vehemence of the cough.'' Dickinson also 
remarks that one attack of the epidemic disease does not protect from a sec- 
ond. One patient had at intervals four distinct attacks, the last being fatal. 
The fact of the recurrence of the throat affection is sufficient proof of its 
diphtheritic rather than scarlatinous nature, as is also the fact that the cha- 
racteristic pellicular inflammation sometimes occurred upon abraded or 
wounded surfaces at a distance from the fauces, while the latter was but 
slightly or not at all affected. This widespread and gradually extending 
epidemic of diphtheria was the first occurring within historic times in North 
America and probably in the Western hemisphere. 

The Hon. Cadwallader Colden, Esq., His Majesty's Lieutenant-Governor 
of the State of New York, wrote a letter to Dr. Fothergill in 1753, printed 
in the London Medical Observations and Inquiries, vol. i. He writes that 
this new throat disease extended gradually westward from Kingston, tra- 
versing New England, but it did not reach the Hudson river until two years 
had elapsed. Colden said that it remained for some time on the east side 
of the Hudson, but finally crossed to the west side, and he believed that it 
spread over all the British colonies in America. As might be expected, in 
due time it reached New York, and it was described by Dr. Samuel Bard in 
a paper published in 1771 and having the following title : " An Inquiry into 
the Nature, Cause, and Cure of the Angina Suffocativa, or Sore-throat Dis- 
temper." Bard wrote as follows : " Upon the whole, therefore, I am led to 
conclude that the disease called by the Italians morbus strangulatorius ; the 
croup of Dr. Home ; the sore throat of Huxham and Fothergill ; this disease, 
and that described by Dr. Douglass of Boston, however they may differ in 
the symptoms of putrescence and malignancy, do all bear an essential affin- 
ity and relationship to each other, and in fact arise from the same leaven." 
Dr. Jacob Ogden of Jamaica, Long Island, described this widespread throat 
distemper as he observed it in the townships of Long Island. His last paper 
on this malady was published in 1774, thirty-nine years after the first case in 
Kingston, and just before the breaking out of the Revolutionary war. I am 
not aware that any outbreak of diphtheria occurred in this country during 
the eighteenth century after the commencement of the war. The fact that 
families deserted their homes and fled to a distance for safety, especially 
from the cities along the Atlantic coast, may aid in explaining the disappear- 
ance of this disease. After the disappearance of this widespread epidemic 
we hear little or nothing of the occurrence of diphtheria upon this continent 
until nearly a century had elapsed, except that occasional isolated cases of 
pseudo-membranous laryngitis, popularly designated membranous croup r 
occurred now and then with little evidence of contagiousness. It may 
have been produced by the streptococcus and have been a croup of the 
pseudo-diphtheritic nature. 

In the first half of the present century diphtheria was regarded as a very 
important disease in Europe, and was made the subject of investigation by 
the most renowned clinical teachers, among whom we may mention Jurine 
(1807), Bretonneau (1821), Bourgeoise (1823), Gendron (1825). Billard 
(1826), Deslandes (1827), Blanquin (1828), Broussais (1829), Trousseau 
(1830), Cheyne (1833), Fricout and Burley (1836), Boudet (1842), Guersant 
and Blache (1844), Moland (1845), Damot (1846), and Heine (1849). During 
this half century, ending with 1850, which witnessed such an augmentation 
of the literature of diphtheria in Europe, this disease attracted but little 
attention in America. It appears to have been much less prevalent on this 
continent than in the Old World. It may have occurred in small epidemics 
in various localities from the time of Dr. Bard until 1850, but they attracted 
so little notice from American physicians that no monograph or communica- 



DIPHTHERIA. 331 

tion to medical journals relating to diphtheria, which was worthy of preserva- 
tion, appeared during this long period. 

Etiology. — Diphtheria is caused by a bacillus, which alights upon the 
faucial or other mucous surface, or the skin denuded of its epidermis, and 
obtains there a nidus favorable for its development and propagation. It is 
designated the Klebs-Loeffler bacillus, having been discovered by Klebs in 
1883, and subsequently more fully investigated by Loeffler. It is a small 
linear microbe, having nearly the length of the tubercle bacillus, but ordi- 
narily more than double its thickness. It often exhibits a granular appear- 
ance, and is stained in two minutes by the violet of methyl. It presents 
aspects which under the microscope are characteristic. It often exhibits a 
more intense coloration of its extremities than of its central parts. Both its 
extremities are sometimes swollen, so that its shape approximates that of the 
dumb-bell, or only one is swollen, so that its shape resembles that of the pear 
or gourd. 

According to all bacteriologists this bacillus does not enter the internal 
organs except in rare instances. It does not ordinarily extend more deeply 
than the mucosa, the parts below being protected by a layer of fibrinous 
lymph. 

Since the specific bacillus ordinarily acts only on superficial parts, it does 
not in itself produce systemic or blood poisoning, but it generates a toxine 
which is readily taken up by the lymphatics or blood-vessels and is conveyed 
to every part of the system, causing the systemic infection from which so 
many of the victims of diphtheria perish. 

L. Brieger and Karl Fraenkel say of this toxine that it is destroyed by a 
heat above 140° F. (60 C), and may be evaporated at 122° F. (50 C). It 
is soluble in water, but insoluble in alcohol. It is not precipitated by ebul- 
lition, nor by the following medicinal agents : sulphate of sodium, nitric acid, 
and acetate of lead, but is precipitated by concentrated carbolic acid, the 
ferrocyanide of potassium, acetic acid, carbolic acid, and nitrate of silver. 
It has the following composition : 

Carbon 45.35 

Hydrogen . '. 7.13 

Azote 16.33 

Sulphur 1.39 

Oxygen . 29.80 

The investigations of Boux, Yersin, and others have shown that the 
diphtheria bacillus separated by passing through the Pasteur-Chamberland 
porcelain filter, and becoming separated from its toxine, loses its virulent 
property, while the clear filtered fluid, free from microbes, contains the 
toxine without diminution of its poisonous character. Grandmaison says 
that although the Klebs-Loeffler bacillus appears only on superficial inflamed 
parts, the poison generated by it entering the system causes paralysis, gan- 
glionic engorgement, albuminuria, patches of sphacelus, and visceral lesions. 
which, although they may be latent during life, are discovered by micro- 
scopic examination of the diseased viscera in the cadaver. 

Although the Klebs-Loeffler bacillus is the recognized cause of true 
diphtheria, certain accessory germs, mainly cocci, occur during the course 
of the attack, in the pseudo-membrane, upon and in the inflamed surface, 
and also in internal organs, if the disease be severe, having obtained a nidus 
favorable for their development in and upon the diseased parts. It appears, 
from examinations made, that these accessory germs are, in some eases, taken 
up by the lymphatics and blood-vessels, and conveyed to the lymph-nodes 
and the connective tissue of the neck, causing inflammatory tumefaction, and 



332 COXSTITUTIOXAL DISEASES. 

to internal organs which are not reached by the Loeffler bacillus. These acces- 
sory germs increase the severity and mortality of true diphtheria. Their 
presence as a complication is an interesting fact, because, as we will see, the 
streptococcus and. in a less degree, other forms of cocci, unaided by the 
diphtheria bacillus, sometimes cause so severe an inflammation of the mucous 
surface that fibrin exudes, producing a pseudo-membrane. 

Klebs-Loeffler Bacillus in Healthy Individuals. — Roux and Yersin have 
found in the mouths of healthy children and adults a bacillus which, in a 
morphological point of view, is identical with the Klebs-Loeffler bacillus. 
They found it not only in Paris, but also at a distant village situated near 
the sea where diphtheria had not occurred within the memory of man. In 
this village Roux and Yersin examined 50 children and found this benign 
bacillus in 26. It does not differ from the Klebs-Loeffler either in its indi- 
vidual form or in the form of a colony, but only in the number of its 
colonies. Instead of producing a considerable culture in the bouillon, it 
only produces a slight culture. Hence Roux and Yersin believe that this 
harmless bacillus is none other than the Klebs-Loeffler, deprived of its viru- 
lence. They have been unable to produce its transformation into the genuine 
diphtheritic bacillus or the reverse, but do not doubt that this transformation 
is possible. This innocuous bacillus has been found most frequently in benign 
diphtheria and in persons recently cured of diphtheria. 

Dr. W. H. Park writes as follows upon this subject: ' : In 1888 Hofmann 
states that besides finding the diphtheria bacilli in cases of true diphtheria. 
he had found them in twenty-six out of forty-five throats in which no diph- 
theria had existed. Some of these bacilli were shorter, thicker, and more 
regular in form than the Loeffler bacilli, and grew more readily on agar, the 
growth being more luxuriant and whiter. Others, however, were in all 
respects identical with the Loeffler bacillus, except that those from healthy 
throats were not virulent. He did not feel able to state whether or not these 
two forms were identical with the virulent diphtheria bacilli of Loeffler or a 
different form of bacteria. Loeffler himself and most German writers have 
considered them to be altogether a different form of diphtheria, while Roux 
and Yersin. most French, and some German bacteriologists, look upon them 
as identical. Roux and Yersin, in their studies on diphtheria, gave careful 
attention to the relationship of the so-called pseudo-diphtheria bacillus to the 
true one. The majority of the bacilli they experimented with were identical 
with the Loeffler bacilli in growth, size, and form, and differed simply in not 
possessing virulence/' 

It is well known that the bacillus having its full vitality and virulence 
may remain a long time in the throats of convalescent patients. Escherich 
expresses {Berlin. kUn. Wochen., 1893, Nos. 21-23) the belief that the growth 
of the virulent bacillus sometimes continues for a time in the throats of con- 
valescent patients, who no longer exhibit symptoms of the disease, and is the 
source of infection to others. Thus the nurse in a hospital had the bacilli in 
her throat, and without being diseased herself, gave diphtheria to the children 
intrusted to her care. I have seen recently a malignant case of diphtheria, 
which was apparently contracted by embracing a schoolmate in the street, 
who had to all appearance entirely recovered from a diphtheritic attack, and 
had gone into the street for the first time. 

As in that other microbic disease, erysipelas, one attack does not afford 
protection against a second seizure. The belief has even been expressed by 
certain clinical observers that patients during convalescence are sometimes 
reinfected, by receiving the bacillus from the bedding, curtains or furniture, 
which they themselves have infected. (Plate I.) 

For the excellent representations of cultures of the bacillus of diphtheria 



PLATE I. 




•- - 



Colonies of Diphtheria Bacilli x 124 diam. 



: **»f 




b. r 






Col. Luxuriant Growth. 



Pseudo-diphth. Col. x 124 diam. 



- 



Colonies B. D. x 240 dim 



/ x \ -/ #^ srj; 



\ <^- 



*v/^ 









Diphtheria Bacilli x 1000 diam. 



>* 









•&\ 



v VfVx*^, ,' 



Characteristic Diphtheria Bacilli x 1000. 






K \ 




Characteristic Diphtheria Bacilli x 1000. 



PLATE II. 



Even-stained short Diphth. Bacilli x 1000. Same as last but grown on Agar x 1000. 



«fti 



Diphtheria Bacilli. Agar culture x 1000. Pseudo-diphtheria Bacilli with a few Cocci. 



■ 



.-. 



Pseudo-diphtheria Bacilli x 1000. 



Pseudo-diph. Bacilli. Agar Culture x 1000. 




Pseudo-diphtheria Bacilli x 1000. 






Vt 



Steptococci. Broth Culture x 1000. 






Steptococci smeared directly upon cover gh 
from Throat Exudate x 1000. 



Same from Serum Culture x 1000. 



DIPHTHERIA. 333 

(Plates I and II) I am indebted to the kindness of the New York Board of 
Health. 

Vitality of the Klebs-Loejfler bacillus. — D'Espine and E. de Mariqual state 
that cultures kept sixteen months have retained their primary virulence. M. 
Sevestre quotes instances in which the contagion of diphtheria, after being 
latent for long periods, communicated the disease. Thus a girl in a locality 
where there was no diphtheria, examined the clothes worn by her mother, 
who had died of this disease two years previously, the clothes having been 
in a chest during this time. After about the usual time she was attacked 
by diphtheria. A brush used for swabbing the throat of a child having 
diphtheria was wrapped in paper and laid aside. Four years subsequently, a 
man having simple sore throat made an application to it with the brush, and 
his fauces soon after became the seat of a diphtheritic exudate. A severe 
and fatal epidemic of diphtheria occurred in a Norman village. Twenty- 
three years had elapsed and no recent case of diphtheria had occurred at or 
near the place, when excavations were made in the graveyard, and the bodies 
of those who died of diphtheria, nearly a quarter of a century previously 
were disturbed. The son of the grave-digger, who had collected the bones 
of the victims of diphtheria and had piled them together, was immediately 
afterward attacked with this disease. He was the first patient in the epi- 
demic which followed. Sevestre relates other cases showing the remarkable 
vitality of the Klebs-Loeffler bacillus, which it is probable from authentic 
observations, remains latent, not only for months but years, and subsequently 
becomes active under favorable circumstances. 

Pseudo-diphtheria or Diphtheroid, a pseudo-membranous inflammation 
caused by the streptococcus and to a less extent by other forms of cocci. 

In a paper read before the Berlin Medical Society by Baginsky, and dis- 
cussed by Virchow, Henoch, Guttmann, Fraenkel, Bitter and others, Bagin- 
sky stated that he had made tube-cultures from the false membrane of all 
the cases of sick children admitted into the hospital during the preceding 
year with the diagnosis of diphtheria. He obtained cultures of the Klebs- 
Loeffler bacillus in 118 out of 154 cases. In most of these cultures the 
microbes associated with the bacillus disappeared during the cultivation, 
while the bacillus multiplied, was typical, and was easily recognized. In the 
remaining 36 cases cultivation yielded no bacillus, but only cocci ; and 32 of 
these recovered in a few days without any complication. Of the four who 
died two had empyema, one pneumonia complicating measles, and the remain- 
ing one had severe paralysis at the time of admission. 

True Pseudo-diphtheria 

Diphtheria. (due to cocci). 

Baginsky 118 cases. 36 cases. 

T. M. Pruden " 24 " 

M. Martin 128 " 72 " 

Wm. H. Park 127 " 114 " 

CarlJanson 63 " 37 " 

The distinguished bacteriologists and clinical observers present at the 
Berlin Medical Society as stated above, and who expressed their views. 
agreed in the main that it is proper to recognize a true diphtheria produced 
only by the Klebs-Loeffler bacillus, and another form of pseudo-membranous 
inflammation, presenting similar gross anatomical characters to those in true 
diphtheria, but caused by cocci (mainly the streptococcus and staphylococcus). 
The latter is designated pseudo-diphtheria, in order to distinguish it from 
true diphtheria or that caused by the Klebs-Loeffler bacillus, and this nomen- 
clature or distinction is commonly accepted by bacteriologists in both hemi- 



334 CONSTITUTIONAL DISEASES. 

speres. Pseudo-diphtheria like true diphtheria is accompanied by fever, 
tumefaction of the lymphatic glands, and is much less fatal than genuine 
diphtheria. The preceding table shows the relative frequency of true and 
pseudo-diphtheria, as ascertained in different laboratories by the examinations 
of specimens. 

Mixed Infection. — Although the term true diphtheria is applied to that 
form of pseudo-membranous inflammation which is caused by the Klebs- 
Loeffler bacillus, and pseudo-diphtheria to that which is caused by other 
microbes, the two having different toxines must be entirely distinct from 
each other in their essential nature however close their resemblance. Never- 
theless, an accurate diagnosis is often rendered more difficult by the fact, 
which is more and more recognized, that in a large proportion of cases there 
is a mixed infection, that is the coexistence of the Klebs-Loeffler bacillus and 
forms of cocci which are pathogenic. Of course a patient who is sick from 
the combined action of the diphtheria bacillus and of cocci which penetrate 
the system is less amenable to treatment than one in whom only one form 
of microbe is present. 

Dr. I. L. Morse has published the following statistics relating to the 
etiology and pathology of diphtheria and pseudo-diphtheria : 

Percentage of 
Mortality. 

Klebs-Loeffler alone in 46 cases of which 20 died 43 per cent. 

" " with streptococci in 21 cases of which 6 died .28 " 

" with staphylococci in 93 cases of which 43 died, 46 " 
" with streptococci and staphylococci in 77 cases 

of which 29 died . . 38 " 

" " with others in 3 of which 1 died 33 " 

Streptococci alone in 18 of which 1 died 5 " 

Staphylococci alone in 27 of which 15 died 40 " 

Staphylococci and streptococci 99 of which 19 died 19 " 

Others in 5 of which 2 died 40 " 

Although the toxine generated by the Klebs-Loeffler bacillus is more 
fatal than any of the cocci or than any toxine generated by cocci, the com- 
bined action of the two evidently produces the highest mortality, and the 
least amenable form of diphtheritic disease. The internal inflammations, as 
broncho-pneumonia, which are so liable to occur in cases of mixed infection, 
are believed to be mostly due to cocci, since these organisms penetrate the 
system. The opinions of distinguished bacteriologists confirmatory of this 
statement might be mentioned. (Plate II.) 

Age. — Most of the published statistics relating to the ages of diphtheritic 
patients evidently embrace all cases of pseudo-membranous inflammation, 
whether the cause be the Klebs-Loeffler bacillus or streptococcus and staph- 
ylococcus — in other words, whether the disease be diphtheria or pseudo-diph- 
theria. Trousseau has said that diphtheria does not spare any age, but is 
most common between the ages of two and five or six years. Guersant 
believes that the age of greatest frequency is between the second and seventh 
years, and Barthez and Rilliet agree with him. Buillon-Lagrange in 73 cases 
occurring in one epidemic treated — 

Under 2 years 14 cases. 

From 2 to 6 years 18 " 

" 6 to 12 " " 10 " 

" 12 to 18 " 9 " 

" 18 to 20 " 15 " 

" 20 to 40 " 4 " 

" 40 to 50 " 1 " 

Above 50 " -. . 2 " 



DIPHTHERIA. 335 

According to M. Barthez, in Sainte-Eugenie Hospital during twenty years 
the ages of the diphtheritic patients were as follows, adults being excluded 
from this institution : 

Under 1 year 81 cases. 

From 1 to 2 years 314 " 

• 2 to 3 " 319 " 

" 3 to 4 " 292 " 

" 4 to 5 " 200 " 

" 5 to 6 " 103 " 

" 6 to 7 " 59 " 

" 7 to 8 " 36 " 

" 8to 9 " 24 " 

" 9 to 15 " 82 " 

" 15 to 17 " 2 " 

Louis has observed that diphtheria may occur at an advanced age, but 
that it is infrequent after the age of forty years, and rare after sixty years. 

As in scarlet fever, so in diphtheria, cases are infrequent under the age 
of six months. Oertel says : " In the first half year the infant organism 
seems to be not at all susceptible to the disease." Nevertheless, cases are on 
record showing that pseudo-membranous inflammation due to microbes does 
occur even in the newly-born. Dr. Abraham Jacobi says : " I have met with 
three cases of diphtheria of the pharynx and larynx myself. One of these 
became sick on the ninth day after birth, and died on the thirteenth day ; 
the other died on the sixteenth day after birth ; the third was taken when 
seven days old, and died on the ninth day" (Treatise on Diphtheria, 1880). 
The following cases of diphtheria in the newly-born have also been reported : 

Number. Age. Author. 

1 14 days Ligri. 

1 15 " Bretonneau. 

1 17 " Bednar. 

1 8 " Bouchut. 

1 7 " Weikert. 

Several cases . Parrot. 

18 Eiredey. 

A disease of the newly-born has occasionally been observed in maternity 
wards which seems to be of diphtheritic origin, but which presents unusual 
features. Thus, Dr. W. S. Bigelow reports in the Boston Medical and Surgical 
Journal, for March 11, 1875, ten cases occurring in the latter part of 1873 in 
the Boston Lying-in Asylum, all fatal but two. The prominent symptoms 
and anatomical characters were a dark hue of the skin, hasmaturia, pseudo- 
membranous exudation upon certain mucous surfaces, dark-green stools, 
enlarged and dark spleen, engorged kidneys ; in some of the cases effusion 
of blood into the pelves of the kidneys and along the urinary tract. 

A case similar to those observed by Dr. Bigelow came under my notice. 
Malignant diphtheria occurred in a family in West Fifty-third Street in 1880. 
The patient, a boy of ten years, died, and the remaining two children, as soon 
as the nature of the malady was apparent, were sent from the house. Never- 
theless, one of them, seven days after the removal, was attacked with diph- 
theria of the hemorrhagic form, and died in less than one week. Blood 
escaped from the nostrils, from the fauces, from the vessels under the skin 
in numerous places, causing hemorrhagic spots, and from the kidneys or 
urinary tract, causing hematuria. The mother suffered great mental depres- 
sion, although her general health seemed good. Her infant, born three 
months subsequently to the occurrence of diphtheria in her family, was well 



336 CONSTITUTIONAL DISEASES. 

developed, but it presented also a similar hemorrhagic cachexia. Blood 
escaped from the vessels under the skin, causing blotches and prominences, 
and from the mucous surfaces. The bleeding was persistent and copious 
from the umbilicus, so that death occurred in less than a week. The poison 
elaborated by microbes is subtle and penetrating, causing the specific inflam- 
mation in the uterine walls of the parturient woman, even when her fauces 
are not affected ; but the exact causal relation of diphtheria or pseudo-diph- 
theria to cases like the above must be determined by future observations. 

It is certain that pseudo-membranous inflammations of a microbic cha- 
racter sometimes appear in newly-born infants. An epidemic of this occurred 
in the New York Infant Asylum in 1887. Five infants under the age of 
thirty-seven days had the pseudo-membranous exudate upon the surfaces 
which are usually affected, but this was before the distinction was made 
between true diphtheria and pseudo-diphtheria based upon different microbic 
causes. Prof. Prudden, who conducted one of the post-mortem examinations, 
made the following record : " The anatomical diagnosis, then, is diphtheria 
of pharynx, larynx, and trachea, with double broncho-pneumonia, localized 
septic inflammation of the umbilical vein and hypogastric arteries and the 
abdominal wall surrounding them." This epidemic in the infant asylum, so 
far as could be determined by laboratory cultures and investigations, was 
produced, not by the agency of the Klebs-Loeffler bacillus, but by the strep- 
tococcus. Probably, therefore, the epidemic was one of pseudo-diphtheria, 
and not of diphtheria. 

Incubative Period. — In inoculated animals this is from twelve hours to 
three days. In Trendelenberg's experiments the incubative period was 
mostly from one to three days ; in Lagrave's about twenty hours. In 
Duchamp's inoculations the animals died after forty-eight hours, with the 
larynx and trachea, upon which the infectious material was applied, covered 
with pseudo-membrane. Oertel says that the rabbits upon which he experi- 
mented by inoculation of the muscles perished in from thirty to thirty-six 
hours, rarely after forty-two hours, the disease-process extending rapidly to 
neighboring tissues. When diphtheria is contracted by a child upon a wounded 
surface the incubative period, although short, may extend four days. The 
history of such a case was contributed by Mr. Phillips to the British Medical 
Journal. Instruments which had been employed in performing tracheotomy 
in a case of diphtheritic croup were in a few hours used for circumcision. 
Four days later the wounded prepuce was covered with a pseudo-membrane 
which extended over the glans, causing much oedema of the prepuce and 
retention of urine. 

When diphtheria is contracted in the usual manner — that is, by the inspi- 
ration of air containing the specific principle — the period of incubation appears 
to be somewhat longer than when it is communicated by direct contact. My 
observations lead me to believe that when the incubative period is short the 
disease is likely to be severe, and when the incubative period is long the 
attack is mild. I was enabled to ascertain very nearly the incubative period 
in the following cases : A boy of nine years was in the same room about one 
hour on Saturday with a child who had fatal diphtheria. On the following 
Tuesday, without any other exposure, he sickened with a fatal form of the 
malady. Mrs. E. assisted in nursing a severe case of diphtheria from Novem- 
ber 11 to 13, 1874, after which she returned home, several blocks away. On 
the evening of the 15th she complained of sore-throat, and on the following 
day the diphtheritic exudate was observed upon her tonsils. On the 19th, 
the pellicular formation had disappeared and she was convalescent. On the 
20th, her sister, who resided with her, and who had not been elsewhere 
exposed, was also attacked. In three other cases which came under my 



DIPHTHERIA. 337 

observation the incubative period seemed to be accurately fixed at six to 
seven days. Sarini says that the incubation, so far as could be determined, 
was as follows : 

From 1 to 2 days 7 cases. 

" 2 to 8 " 48 " 

" 8 to 13 " 23 " 

" 13 to 15 " 6 " 

" 15 to 20 " 14 " 

Modes of Propagation. — No fact is better established than that diphtheria 
does not originate de novo whatever may be the insanitary conditions. It 
is produced by the reception in or upon some parts of the system of the pre- 
existing specific germ. Its extreme contagiousness from person to person is 
well known. A moment's exposure to the breath of a patient, or in the 
infected room where he is under treatment or has been perhaps weeks or 
months previously, has in numberless instances communicated the disease. 
The virus adheres tenaciously to objects on which it happens to. alight. The 
clothing of a patient, even when the disease has been in its mildest form, his 
bedding, the furniture of his room, and the objects which he handles, may 
for weeks afterward communicate the disease even when transported to a 
distance. A child was for a brief period in a room where diphtheria had 
occurred two months previously, and, after the usual incubative period, 
sickened with the disease. The diphtheritic poison may remain in an active 
state for months between the leaves of a book handled by a patient having a 
mild attack or during convalescence. 

Most of the contagious diseases of children are quickly detected by cha- 
racteristic symptoms or appearances with which the most ignorant families are 
to a certain extent familiar ; but mild diphtheria possesses so few subjective 
symptoms that it is often not suspected or detected even in intelligent families 
who are watchful of their children. Children with mild diphtheria sit among 
other children in the schools, the city conveyances, in the churches and dis- 
pensaries, and frequently communicate to those who are near them a malig- 
nant form of the disease from which the unfortunate victims quickly perish. 
The diphtheritic microbes are so subtle, and their vitality and power of propa- 
gation so great that it is difficult to prevent the extension of diphtheria in 
the schools and places of public resort. 

Many instances are related in which diphtheria is communicated by direct 
contact with some infected solid substance, as a particle of the diphtheritic 
exudate, muco-purulent secretion from an infected surface or the blood of a 
patient. In a considerable number of instances recorded in the literature 
over-anxious and self-sacrificing young surgeons have sucked the obstruction 
from the tracheotomy-tube in cases of diphtheritic croup with perhaps relief 
to the patients, but with the occurrence of fatal diphtheria in themselves 
from the exposure. A diphtheritic conjunctivitis, severe and dangerous to 
the eye, has sometimes occurred in the attending physician or nurse after 
examination of the fauces of the diphtheritic patient, produced probably by 
a particle of pseudo-membrane or muco-pus thrown into the eye by the 
expulsive cough. In these instances of communication by direct contact the 
poison is received either upon one of the mucous surfaces or upon the skin 
denuded of its protecting epidermis. It is well known that filthy accumula- 
tions of all kinds afford a nidus which is favorable for the development of the 
Loefner bacillus. Hence the theory seemed plausible that poisonous gases 
escaping into the nurseries through broken waste-pipes or from decaying refuse 
matter in and around domiciles conveyed the Loeffler bacillus and was the 
source of diphtheria. City physicians who were called to treat diphtheria in the 
22 



338 CONSTITUTIONAL DISEASES. 

small, damp, dark, and dirty apartments of the tenement-houses and inhaled 
the foul gases were led to the irresistible conviction that these gases were the 
vehicle of the fatal bacillus. But investigations relating to the nature of 
sewer-gas have shown that this belief that sewer-gas is the carrier of the 
Loeffler bacillus is probably untenable. Mr. L. Parry Laws presented to the 
Main Drainage Committee of London the results of his investigations relating 
to the composition of sewer-gas, undertaken at their request. His examina- 
tions, as well as those previously made by Connolly and Haldane, showed that 
the air of sewers contained about twice the quantity of carbonic acid and about 
three times the quantity of organic matter above that found in the external air 
at the same time. Moreover, the sewer-air contained a smaller number of micro- 
organisms than the air which they examined in domiciles. Mr. Laws found 
that the micro-organisms of the sewer-gas were related to those of the air 
outside, and the forms present were almost wholly moulds and micrococci. 

Investigations like those related above have led to the belief on the part 
of many bacteriologists that sewer-gas does not convey the Loeffler bacillus 
into domiciles through untrapped or defective waste-pipes, as was formerly 
believed ; but the causal relation of this gas to diphtheria is like other foul 
exhalations which cause deterioration of the system, weaken the powers of 
resistance, and render the action of the diphtheritic bacillus which happens 
to be present more virulent and fatal. Probably the sewer and other fetid 
gases increase the virulence of the Loeffler bacillus, and perhaps, under cer- 
tain circumstances, it renders the benign bacilli virulent, but this, however 
plausible, has not been proven. 

Diphtheria contracted from Animals. — Observations are accumulating 
which show that diphtheria occurs in certain domestic animals and is some- 
times communicated from them to man. That certain animals are liable to 
it has been shown by inoculations in many laboratories, made for experimental 
purposes. The feathered tribe especially appear to be susceptible to this 
disease. On the island of Skiathos, off the north-eastern coast of Greece, no 
diphtheria had occurred during at least thirty years previously to 1884, 
according to Dr. Bild, the physician of the island. In that year a dozen 
turkeys were introduced from Salonica. Two of them were sick at the time 
and died soon afterward ; the others became affected subsequently, and of the 
whole number seven died, three recovered, and two were sick at the time of 
the inquiry. These two had laryngeal obstruction with difficult breathing and 
swelling of the glands of the neck. As further evidence that the disease was 
true diphtheria, one of the turkeys that survived had paralysis of the feet. 
The turkeys were in a garden on the north side of the town, and the pre- 
vailing winds from the island are from the north. When this sickness was 
occurring among the turkeys an epidemic of diphtheria commenced in the 
houses nearest to the garden and spread through the town. It lasted five 
months, and, of one hundred and twenty-five cases in a population of four 
thousand, thirty-six died. Diphtheria was from this time established on the 
island, and frequent epidemics of it have occurred since. 1 M. Menzies 2 states 
that diphtheria is common among the poultry in Italy, in which country the 
flat roofs of the houses afford a resting-place for turkeys, fowls, pigeons, and 
rabbits, and their evacuations are carried by the rain into the cisterns and 
wells. A physician at Posilippo, near Naples, had directed his servant not 
to obtain drinking-water from the well next to his house, but from a well at 
a distance. So long as he obeyed the instruction his family was well, but, 
yielding to his indolence, he finally disobeyed the command and obtained 
water from the infected well. Four of the children who drank this water 
took diphtheria and died, while the fifth child, who did not drink it, escaped. 
1 Bulletin Medicale, Jan. 22. 1888. 2 Thesis, Paris, 1881. 



DIPHTHERIA. 339 

Dr. F. F. Wheeler 1 states that while in a nesting of wild pigeons he found 
many sick with a pseudo-membranous sore throat. He dissected many with 
his pocket-knife, which he was obliged to throw away on account of its offen- 
sive odor. There were millions of pigeons in the nesting, and they were 
hunted and eaten by the inhabitants. In the same year diphtheria broke 
out in a most malignant form among the people, causing many deaths. 
Several years previously pigeons nested in the same locality or near by, and 
fully half of the children in the vicinity had diphtheria. 

Dr. Geo. Turner 2 states that a pigeon was brought to him for dissection. 
The whole of its windpipe was covered by a pseudo-membrane, as in the 
croup of a child. Pigeons were inoculated in the fauces with this mem- 
brane, and a similar disease was produced, which extended to their eyes 
through the nostrils. Dr. Turner also related several other epidemics of 
diphtheria in different localities, accompanied by a fatal pseudo-membranous 
inflammation in the feathered tribe, the poultry, turkeys, pigeons, and in one 
locality the pheasants. At Tougham a man bought a chicken at a low price, 
as it was affected with the prevailing disease, and cared for it at his home. 
Soon after diphtheria broke out in his family and this case was the first in 
the village. Bilhaut 3 states that a pigeon-fancier had lost several birds by 
disease. He endeavored to save one of them that was sick by allowing it to 
pick food from his tongue. The pigeon died and an examination showed 
that it died of diphtheria. Before its death the man sickened with diph- 
theria and pseudo-membranes formed underneath his tongue on either side 
of the fraenum, where the bird had picked its food, and also upon his tonsils. 
Recently also M. Cagny has related cases showing the propagation of diph- 
theria from the feathered tribe to man. 4 Did time permit other similar cases 
might be related published in American medical journals. 

Bacteriologists in their experiments have demonstrated the fact that 
certain quadrupeds used for experimental purposes contract diphtheria. 
Trendelenberg inoculated sixty-eight rabbits introducing diphtheritic pseudo- 
membrane through an artificial opening. Eleven of the rabbits died with the 
symptoms and appearance of diphtheria. In control experiments he intro- 
duced various foreign bodies into the larynx of rabbits, and was unable to 
produce results or lesions resembling those in diphtheria. Oertel performed 
twelve similar experiments, and five of the rabbits died after the production 
of pseudo-membranes. Zahn, Gerhardt, Labadie-Lagrave, Francotte, Bates- 
Klein, and Yulpian may be mentioned among those who have obtained similar 
results from their inoculations. Bruce Low, in his report to the Local Gov- 
ernment Board, 5 states that a little boy at Enfield had fatal diphtheria, and 
vomited on the first day of his illness. A cat licked the vomited matter 
from the floor, and soon after the boy's death it was noticed to be ill, and 
its suffering and symptoms so closely resembled those of the dead boy's that 
it was destroyed by the owner. During the first part of its sickness the ani- 
mal was allowed to go out in the back yard, and a few days subsequently 
the cat of a near neighbor became ill. This cat had frequented the back 
yard. It was nursed during its sickness by three little girls, all of whom 
took diphtheria. Lawrence 6 reports two cases in which diphtheria seems to 
have been communicated by cats. In the first case, that of a little girl, a 
careful inquiry showed that the child had not been exposed to any case. 
although diphtheria was prevailing within a mile of the patient's residence. 
but she had fondled a sick cat a few days before. The cat died some time 

1 American Practitioner and News. 2 Journal of Laryngology and Bhinology. 

3 Journal de Medicine de Paris, July 13, 1890. 

4 Journ. de Medicine, July, 1890. ' 5 British Med. Journ,, May 10, 1S90. 
6 Med. Press and Circular, London, June 4, 1890. 



340 CONSTITUTIONAL DISEASES. 

afterward, and a second cat became sick and was killed. Inquiry disclosed 
the fact, that a neighboring farmer had lost seventeen cats and* another 
fifteen cats, from a throat distemper, and one of the farmers stated that he 
had examined the throats of some of the cats and found them covered with 
a white membrane. S. C. Coleman 1 of Colorado, Texas, states that after a 
residence of five years in Colorado he saw the first case of diphtheria. A 
child of five years, living thirty miles distant in the country, with no neigh- 
bor within six miles, had diphtheria followed by paralysis. Being far from 
any source of human contagion, this child had rarely seen other children. 
The father stated that two kittens had recently died of what seemed to be 
the same disease as that of the child, who had nursed them and frequently 
kissed them. The risk of fondling diseased cats, which are pets of the nursery, 
cannot be too strongly stated. 

Many observations have shown during the last few years that milk affords 
a favorable nidus for the propagation of the Klebs-Loeffler bacillus, and that 
occasionally epidemics are produced by an infected milk-supply. In 1879, 
Mr. Wm. H. Power, health inspector, investigated an outbreak of diphtheria, 
and believed that he traced it to the milk. The cows that furnished the milk 
that apparently caused the diphtheria, had what the veterinary surgeons 
designated " garget " or " infectious mammites." Gooch has described an out- 
break of diphtheritic tonsilitis in Eton College which he traced to the milk 
supplied. The cows furnishing milk drank water which contained sewage 
from a neighboring farm. The investigation showed that the milk when 
boiled was harmless, since the boiling destroyed the germs, but when used 
unboiled the disease was communicated. The cows were removed to another 
pasturage, where the water used by them was different, and the epidemic 
ceased. The disease was in all instances propagated by the milk supply. 
Observations therefore show that milk, which is the culture medium of vari- 
ous pathogenic microbes, is sometimes the medium of the communication of 
diphtheria, as it is known to be of scarlet fever. 

Diagnosis. — No more important duty devolves upon the physician than 
that of making an early and correct diagnosis of diphtheria and of those mal- 
adies of the throat which resemble diphtheria in appearance, but are in their 
nature distinct from it. If the case be one of diphtheria, its nature should 
be recognized at the beginning, so that proper remedial measures be employed 
as well as measures designed to prevent propagation. If the disease be not 
diphtheria, a correct diagnosis is required so that needless treatment and 
alarm be prevented. In many cases the diagnosis is easy or highly prob- 
able after diphtheria has continued twenty-four hours, since in addition to 
the fever and pain in swallowing, the characteristic whitish-gray pellicle has 
begun to form on one or both tonsils. If the exudate be not limited to the 
tonsils, but extend to the fauces, and cover more or less the pillars and arch 
of the palate and the uvula, the disease is probably diphtheria. Still cer- 
tainty in regard to the nature of the disease in many instances requires a 
microscopic examination. Prof. H. M. Biggs 2 of the New York Health Board 
states that within a certain time of the large number of suspected cases of 
diphtheria removed from the tenement houses and slums of New York to the 
Willard Parker Hospital, 30 to 50 per cent, of them did not have true diph- 
theria, but pseudo-diphtheria or pellicular inflammation, caused by forms of 
cocci, especially by the streptococcus. The result of treatment corresponded 
with that observed elsewhere, for of those shown by the microscope to have 
true diphtheria, 20 to nearly 50 per cent, perished ; while of those that had 
pseudo-diphtheria, the mortality was from 1 to nearly 5 per cent. 

Like other well-known bacteriologists, those doing the bacteriological 

1 New York Medical Record, Nov., 1890. 2 Journ. of Laryngology, Sept., 1894. 



DIPHTHERIA. 341 

work of the Xew York Health Board have been able to produce cultures and 
make returns, indicating the nature of the disease in from twelve to twenty- 
four hours. The following is extracted from the report of Dr. Biggs : 
" During the past three'months four hundred and five cases of true diphtheria 
have been subjected to repeated bacteriological examinations, performed at 
short intervals during the course of the disease, and during convalescence. 
In all of these cases cultures were made at the beginning of the disease, again 
after the lapse of three or four days, and finally at short periods after the 
complete disappearance of the false membrane, until the throat was found to 
be free from the diphtheria bacillus. In two hundred and forty-five of these 
four hundred and five cases the diphtheria bacilli disappeared within three 
days after the complete separation of the false membrane ; in one hundred 
and sixty cases the diphtheria bacilli persisted for a longer time — namely, in 
one hundred and three cases for seven days ; in thirty-four cases for twelve 
days ; in sixteen cases for fifteen days ; in four for three weeks, and in three 
for five weeks after the time when the exudation had completely disappeared 
from the upper air-passages. 

" In many of these cases the patients were apparently well many days 
before the infectious agent had disappeared from the throat. These results 
show that in a considerable proportion of cases persons, who have had 
diphtheria, continue to carry the germs of the disease in their throats for 
many days after all signs and symptoms of the disease have disappeared. 
No doubt the disease is largely disseminated by these persons, who are appar- 
ently well, and who mingle with others while their throat secretions still con- 
tain the diphtheria bacilli. 

u These experiments have led the Health Department to adopt the rule 
that no person who has suffered from diphtheria shall be considered free from 
contagion until it has been shown by bacteriological examination, made after 
the disappearance of the membrane from the throat, that the throat secre- 
tions no longer contain the diphtheria bacilli, and that until such examina- 
tions have shown such absence all cases in boarding houses, hotels, and tene- 
ment houses must remain isolated and under observation. Disinfection of 
the premises, therefore, will not be performed by the department until exam- 
ination has shown the absence of the organisms." 

Let us more closely compare the diagnostic characters of diphtheria with 
those of other and distinct diseases from which it is very important that 
diphtheria should be differentiated in practice. 

Pseudo-diphtheria or Diphtheroid.— Perhaps, I have already sufficiently 
stated the diagnostic characters of this disease. Pseudo-diphtheria is pro- 
duced by the streptococcus, sometimes associated with other forms of cocci. 
The streptococcus does not generate so deadly a poison as that of the Klebs- 
Loeffler bacillus. Consequently, the systemic infection in true diphtheria is 
much more fatal than in pseudo-diphtheria. While the Klebs-Loeffler bacil- 
lus does not enter the system, or rarely does so ; the forms of cocci do, and there 
is frequently a mixed infection, the Loeffler bacillus being present with the 
streptococcus and staphylococcus. But diphtheria and pseudo-diphtheria, 
although their differential diagnosis is, in many instances, difficult or impos- 
sible without bacteriological examination, require essentially the same treat- 
ment. 

Follicular Pharyngitis or Tonsillitis. — This is a common disease, most 
likely of microbic origin. It frequently extends through families, all or most 
of the children being affected by it. It is attended by fever, dysphagia, and 
an inflammatory hyperemia, not only of the tonsils, but of the pharyngeal 
surface generally. It commences suddenly like diphtheria, with headaches, 
chilliness, heat of surface, the temperature often rising to 103° Fall., languor 



342 CONSTITUTIONAL DISEASES. 

and frequently pain in the back and extremities. The dysphagia attracts 
attention to the fauces, the surface of which is seen to be hypersemic, espe- 
cially its tonsilar portion. In a few hours a whitish material exudes from 
the crypts of the tonsils, forming rounded masses of the size of a small pin's 
head. This secretion, occurring as small rounded salient masses, distinct from 
one another is distinguished by its appearance from the diphtheritic pseudo- 
membrane, which, at first, is a thin pellucid exudate, becoming thicker subse- 
quently. Consisting simply of epithelial cells, held together by the secretion, 
these small rounded masses are quickly detached by the swab or brush, when 
they are found to be friable, readily crushed between the thumb and fingers, 
and having a fetid odor. If two or more of them happen to unite, forming 
an appearance like that of the diphtheritic membrane, they still present the 
same physical characters, and are readily detached from the tonsilar surface 
without hemorrhage. This peculiar secretion of follicular tonsilitis is usually 
limited to the tonsilar portion of the pharynx, and is of short duration, no 
new secretion occurring after two or three days. 

Pultaceous Pharyngitis ; Confluent Muguet. — This form of pharyngitis 
occurs in low or debilitated states of the system. It occurs in protracted and 
exhausting diseases, attended by malnutrition and faulty digestion. As the 
term " pultaceous " indicates, the inflammatory product is soft and friable, 
coming away in fragments when touched by the brush or sponge without 
bleeding or injury to the mucous membrane. Under the microscope it is 
found to consist of epithelial cells, often in fragments, but no fibrin. In cer- 
tain cases to which the term cryptogamic is properly applied, a cryptogam, the 
oidium albicans, is also present. When the substance forming this soft and 
pultaceous pellicle is removed, the mucous membrane underneath is entire, 
hypersemic, and sometimes covered with a newly-formed epithelial layer. 
The appearance of the pultaceous product to the naked eye may closely re- 
semble that in diphtheria, but its friable character, its epithelial nature and 
the absence of fibrin, which the microscope reveals, renders the diagnosis 
certain. 

Scarlatinous Pharyngitis ; often with more or less Gangrene and Con- 
tiguous Inflammations as Adenitis and Cellulitis of the Neck. — As a rule, the 
microbe, which causes the destructive inflammation in the fauces and adja- 
cent parts in scarlet fever is the coccus in its various forms, especially the 
streptococcus (Booker and others). Gangrene of the fauces may supervene 
at any time, and it bears a close resemblance to the destructive action caused 
by the Loeffler bacillus. This bacillus may occur, constituting a true diph- 
theritic complication, but its advent is usually after the scarlet fever has con- 
tinued a few days, when it is announced by an aggravation of symptoms. 
An exact diagnosis must be made by the microscope. 

Herpetic Pharyngitis. — Small vesicular eruptions of short duration some- 
times attend the initial stage, after which small white or grayish-white ulcers 
remain. Their small size and history serve for diagnosis. After ablation 
of the tonsils or injury of the fauces by highly-irritating applications as 
ammonia the appearance, in some cases, closely resembles diphtheria, but it 
is differentiated by the history. 

Anatomical Characters. — Within a day, and usually within a few 
hours, from the commencement of the inflammation a small, slightly-raised, 
whitish or grayish spot or patch is observed, usually upon the tonsilar por- 
tion of the inflamed surface — very significant as a diagnostic sign and as a 
forerunner of what is to happen. This patch, termed the pseudo-membrane, 
gradually becomes firmer, and at the same time thicker and broader from 
fresh exudations underneath. It retains for a time its grayish- white color, 
but it becomes brownish-white from age. In mild cases the pseudo-membrane 



DIPHTHERIA. 343 

is usually limited to the tonsilar surface, but in severe cases it covers the 
uvula, portions of the velum, the isthmus, and the walls of the pharynx, 
both lateral and posterior. It does not ordinarily attain a greater thickness 
than one-eighth to one-sixth of an inch. I have seen it, however, not far 
from one-third of an inch thick. 

The inflamed mucous membrane is not only hyperaemic and infiltrated 
with serum, but it also contains numerous round white corpuscles (leu- 
cocytes), which may result in part from proliferation of connective-tissue 
corpuscles, but are believed by most pathologists, since Cohnheinrs well- 
known discovery, to be in great part wandering white corpuscles of the blood 
which have escaped through the walls of the blood-vessels along with the 
fibrin. In the commencement of the diphtheritic inflammation, before the 
pseudo-membrane forms, we often observe a grayish tinge of the mucous 
surface, which is due to the crowding of the cellular elements in and under- 
neath the mucous membrane ; for these newly-formed cells not only infiltrate 
the mucous membrane, but can also be traced into the submucous con- 
nective tissue. Even where the inflammation remains catarrhal, as it does 
over certain areas in all cases of diphtheria, this infiltration of the mucous 
and submucous tissues with cells is common. 

During the active period of diphtheria it is often astonishing to see with 
what rapidity the pseudo-membrane returns when removed by force. A few 
hours suffice to restore it as firm and extensive as before the interference. In 
the most favorable cases the membrane is detached in a few days, and is not 
reproduced. Its separation is promoted by the secretions underneath, espe- 
cially by pus, which is secreted in abundance between it and the tissues 
underneath, which have preserved their integrity. In most instances it does 
not separate in mass, but disappears by progressive liquefaction. Occasion- 
ally, even in cases which do not present a severe type, the diphtheritic patch 
does not disappear until the lapse of four or five or even six weeks, or if it 
softens and is detached another appears in its place. In these instances of an 
unusual prolongation diphtheria has been designated chronic. 

Such are the appearances, character, and history of the pseudo-membrane 
in this malady. Although its common seat is upon the fauces, and in mild 
cases it is limited to them, nevertheless all the mucous surfaces are liable to 
be attacked by the inflammation in consequence of the infection of the blood, 
and therefore in severe cases, and even in cases of moderate severity, we often 
find the product elsewhere as well as upon the fauces, and in localities where 
from its mechanical effect it greatly increases the danger and even compro- 
mises life. The mucous membrane of the nostrils, mouth, larnyx, trachea, 
bronchial tubes, Eustachian tubes, conjunctiva, oesophagus, stomach, intestines, 
vagina, prepuce, and even the delicate lining membrane of the middle ear, are 
at times the seat of diphtheritic inflammation with the characteristic product. 
In a case which occurred in the Nursery and Child's Hospital of New York 
the surface of the stomach was almost completely lined by the diphtheritic 
formation, so as apparently to abolish the function of this important organ. 
The occurrence of the pseudo-membrane in the nares is common, and is 
attended by the discharge from the nose of thin mucus and pus. Nasal 
diphtheria involves great danger from the fact that it is likely to give rise 
to systemic infection of a grave type. In the nursing infant it is also dan- 
gerous, since by its mechanical effect it interferes with lactation. The thin, 
irritating discharge produces excoriations around the nostrils and upon the 
upper lip. I have met only one case of diphtheritic inflammation of the 
intestines in which the diagnosis was certain. A physician in whose family 
diphtheria was occurring became seriously sick with symptoms which closely 
resembled those of typhoid fever. After a long sickness he expelled per 



344 CONSTITUTIONAL DISEASES. 

rectum about one foot of pseudo-membrane of a cylindrical form, evidently 
derived from the surface of the intestines. In the subsequent months the 
patient suffered from constipation and severe abdominal pains, apparently due 
to contraction in healing of the large intestinal ulcer. Death finally occurred 
from this state of the intestines. The formation of the diphtheritic pellicle 
upon the vulva and vaginal walls is not infrequent, and in parturient women 
exposed to diphtheria . it sometimes occurs upon the uterine walls, usually 
with a fatal result. A considerable number of cases are on record in which 
diphtheritic inflammation occurred upon the prepuce after circumcision, pro- 
ducing the usual pseudo-membrane, and in one instance in my practice, 
referred to above, it attacked the prepuce the day after I had dilated it 
with an instrument clean and free from infection. 

The Blood. — The blood in cases of a severe type is usually darker than in health 
and the clots soft. After death from diphtheritic croup it is also dark from the 
excess of carbonic acid in it. The chemical changes which the blood undergoes in 
diphtheria are partially known. MM. Andral and Gavarret found a notable diminu- 
tion of fibrin in grave infectious diseases, as typhoid fever, puerperal fever, etc., and 
it is not improbable that the same is true of diphtheritic blood, although the exuda- 
tion of fibrin is so abundant. M. Bouchut and others have noticed an excess of the 
white corpuscles in the blood in diphtheritic patients, so that, instead of three or 
four in the field of the microscope, as many as sixty have been counted. M. Sanne 
writes of diphtheria : " It is necessary to recognize in the dark-brown blood an 
abnormal accumulation of the debris of the red corpuscles, debris of little abun- 
dance in the normal state, augmented considerably under the noxious influence 
of the diphtheritic poison, which has rapidly produced destruction of a great 
number of globules." ] Small extravasations of blood in the various organs are 
among the most constant lesions. They have been most frequently observed in the 
brain and its meninges, the lungs, spleen, and kidneys. In one case which I 
examined after death in the Xew York Foundling Asylum the extravasations in 
and under the gastric mucous membrane produced mottling as great as that of the 
skin in measles. 

The most minute examinations of the organs in diphtheria yet published are 
those recently made by Oertel, and we will present a summary of them in the 
following pages. 

Brain and Spinal Cord. — The anatomical changes occurring in these organs 
are in a measure described in our remarks on diphtheritic paralysis. Oertel dis- 
covered, as the earliest anatomical change in the brain and spinal cord as well as 
in the membranes, a venous hyperaemia, with small extravasations of blood, "not 
larger than a pea,"' in the white medullary matter of the brain, while in the corti- 
cal layer and in the central parts no extravasation was found. In the most severe 
forms of the disease small hemorrhages not larger than a pea were found not only 
in the cerebral meninges, but also in various parts of the brain. These produced 
some softening in their immediate neighborhood. These small hemorrhages have 
been found also in or upon the medulla oblongata and spinal cord, but with less 
softening. Buhl, in addition to the extravasations in and upon the brain and 
spinal cord, discovered in one case great enlargement of the anterior and posterior 
roots and the ganglionary swellings of the spinal nerves. The swelling was found 
to be due to the accumulation of cells and nuclei in the sheaths of the nerves and 
to extravasations of blood. These anatomical changes were most marked at the 
roots of the lumbar nerves. (For further particulars relating to the pathology 
of the nervous system in diphtheria the reader is referred to our remarks* on 
Paralysis.) 

Tonsils. — Covering these organs is the pseudo-membrane, consisting of the 
usual fibrillar meshwork, enclosing leucocytes, changed epithelial cells, and amor- 
phous matter : the older the exudation the coarser is the network. The adenoid 
tissue and the septa have undergone hyperplasia. The follicles are crowded with 
cells which have undergone necrobiosis. As a result of the necrobiosis masses are 
formed of various shapes and sizes, staining deeply. In consequence of the necro- 
biosis and degenerative changes the follicles become a hyaline network infiltrated 

1 Trade de la Diphtherie, p. 107, Paris, 1877. 



DIPHTHERIA. 345 

with leucocytes and granules. In advanced cases the adenoid and connective tissues 
undergo a similar necrobiotic change, and are so blended with the pseudo-membrane 
that it is difficult to determine where the latter ends and the tonsilar tissue begins. 
The vessels of the tonsils undergo a hyaline thickening of their walls, and if this 
occur chiefly in the intima total occlusion may result. In the tissues immediately 
surrounding the tonsils hyaline degeneration of the muscular fibres occurs (Zenker's 
degeneration), and the connective tissue between the muscular fibres is infiltrated 
with leucocytes. 

Fancied Surface and Uvula. — These parts are often also covered with pseudo- 
membrane, and are more or less changed by the application of remedies. The line 
of separation of the exudate and underlying tissues cannot be readily distinguished. 
The upper portion of the diphtheritic pellicle is filled with bacteria and with leu- 
cocytes and other cells which have undergone necrobiosis. In the mucosa next to 
the pseudo-membrane hyaline degeneration of the connective tissue occurs, and the 
mucosa is infiltrated with cells which have undergone marked changes. The nuclei 
of the connective-tissue cells exhibit various stages of degeneration and decay, 
though the cells may retain their form. The deeper layers of the mucosa, like the 
upper, are infiltrated with leucocytes. 

The uvula in severe cases is usually swollen and oedematous, and sometimes 
entirely covered by the diphtheritic pellicle. When the uvula is involved in the 
general faucial inflammation, necrobiosis of the cells and nuclei occurs in every 
part of it. The cells in the arterial adventitia and in the perivascular tissue exhibit 
necrobiotic change, their nuclei being disintegrated. In the uvula, also, hyaline 
degeneration occurs in the walls of the vessels. 

Epiglottis. — The epithelial cells covering the epiglottis undergo marked prolif- 
eration early in the disease, and are infiltrated with leucocytes. They soon begin 
to undergo degeneration, forming granular masses. Areas of necrobiosis occur, 
and finally hyaline degeneration of the network takes place. The leucocytes ex- 
tend deeply into the mucous membrane, followed by degenerative and necrobiotic 
changes. In places the epithelium is thrown off, and a pseudo-membrane forms of 
exuded fibrin and necrobiotic leucocytes and epithelium. Bacteria, along with leu- 
cocytes and degenerated epithelial cells, occupy the meshes of the pseudo-mem- 
brane. 

Lungs. — The anatomical characters of the air-passages are fully treated of in 
the article on Diphtheritic Croup. Catarrhal bronchitis is common in diphtheria. 
It is not often absent in croup, and one of the chief sources of danger in this dis- 
ease is the extension of pseudo-membrane from the laryngo-tracheal surface to the 
bronchial, and the transformation of the catarrhal into a croupous inflammation. 
"When bronchitis occurs the inflammation creeps downward gradually from the 
laryngo-tracheal surface, and its severity is proportionate to the degree of extension. 
When there is a general bronchitis and it is very liable to become croupous, the 
muco-purulent exudation is abundant. When . pseudo-membranous bronchitis 
occurs, there are usually portions of the bronchial tree in which the inflammation 
remains catarrhal. One of the chief sources of danger in diphtheritic croup is the 
extension of the inflammation to the bronchial tubes and the abundant secretion of 
muco-pus, which clogs the tubes and prevents proper decarbonization of the blood. 
W^hen the bronchitis becomes croupous, a thin, easily-detached film appears upon 
the intensely-red, hypereemic, and swollen bronchial surface. It increases in thick- 
ness and firmness, and is of a brownish-gray color. Whatever the stage of the inflam- 
mation, the pseudo-membrane can always be readily detached from the bronchial 
surface, since its relation to it is one of apposition, and not of integral connection, 
as upon the pharyngeal surface. In the large tubes and those of medium size 
hollow cylinders, more or less complete, form 5 but in the smaller tubes, if the 
pseudo-membrane extend to them, solid cylinders are produced. Frequently, in the 
bronchial croup of diphtheria, while the entire bronchial surface is intensely red 
and swollen, the pseudo-membrane is absent in certain parts ; in other parts it 
forms cylinders, in other parts still longitudinal bands of a ribbon shape are pro- 
duced, and in more or fewer of the minuter tubes, plugs which entirely fill the lumina 
and prevent the entrance of air exist. The alveoli beyond these plugs gradually col- 
lapse, and more or fewer of them return to the unexpanded foetal state. From the 
tubes which are still pervious the muco-pus is with difficulty expectorated on 
account of its viscidity, and this thick secretion contains floating particles of 
pseudo-membrane. Pseudo-membranous bronchitis in diphtheria is in nearly all 



346 CONSTITUTIONAL DISEASES 

instances an extension of a laryngotracheal croup. It occurs, according to Sanne, 
most frequently between the second and sixth days. 

Various forms of pulmonary disease occur in diphtheria, usually as a complica- 
tion and often as a final result of the downward extension of inflammation from 
the larynx, trachea, and bronchial tubes. Splenization, atelectasis, and broncho- 
pneumonia are common complications of diphtheritic croup. Broncho-pneumonia, 
like pseudo-membranous laryngo-tracheitis and pseudo-membranous bronchitis, 
upon which it largely depends, occurs usually in the first week of diphtheria. In 
121 cases of broncho-pneumonia complicating diphtheria, observed by Sann<?, the 
pneumonia commenced in 2 on the first day of diphtheria and in 71 between the 
second and sixth days inclusive. 

Pulmonary congestion, occupying by preference the depending portions of the 
lungs, especially the posterior and inferior portions of the lower lobes, is also not 
infrequent. It occurs when respiration is obstructed in croup and when the circu- 
lation is feeble in consequence of heart-failure. In the dyspnoea which accom- 
panies paralysis of the pneumogastrics, venous congestion of the lungs commonly 
occurs. 

Peter found the lesions of pleurisy 9 times in 121 autopsies in diphtheria, and 
Sanne observed them in 20 cases. The latter writer says : " All forms of diph- 
theria, but particularly croup and pseudo-membranous bronchitis, are to be found 
with pleurisy. Pleurisy always accompanies some other phlegmasia." 

Vesicular emphysema commonly occurs during the progress of croup. When- 
ever, in consequence of occlusion of the tubes, a considerable part of a lung fails 
to receive air, its alveoli begin to retract and collapse, and the alveoli which receive 
air, which are principally those in the superior and anterior portions of the lung, 
are over-distended, since their function is compensatory. Vesicular emphysema 
consequently results, and in exceptional instances the vesicles rupture and the 
escaped air passes into the connective tissue, producing interstitial emphysema. 

Pulmonary apoplexy occasionally occurs, the extravasations usually being of 
small size and disseminated through the lungs. It is most frequent in malignant 
cases — in cases attended by profound blood-poisoning. It has been attributed in 
some instances to pulmonary emboli resulting from cardiac thrombosis, or microbic 
masses intercepted in the capillaries. Pulmonary oedema also occasionally occurs, 
especially in cases of bronchial croup, pulmonary congestion, and broncho-pneu- 
monia. Oertel in his recent microscopic examinations of the lungs noted sub- 
pleural hemorrhages and hemorrhages extending to the alveoli, which were com- 
pressed. " Leucocytes infiltrated the alveolar septa, and in later stages invaded the 
alveoli, the epithelium of which became detached, and the characters of catarrhal 
pneumonia were thus produced. Some alveoli contained fibrinous exudation, and 
in one severe case the alveolar contents consisted of nuclei which exhibited disin- 
tegrating changes somewhat like those in necrobiosis." 

Lymphatic Glands. — Enlargement of the cervical and submaxillary glands is of 
common occurrence in diphtheria, and it is a diagnostic symptom of some value. 
Hyperplasia of the cells of these glands occurs, with numerous hemorrhagic points 
in their capsules and in the periglandular tissue. Points of necrobiosis, staining 
faintly, occur in the glands, more in the cortical than in the central portions. The 
cells exhibit evidences of disintegration, and when this process is advanced granular 
masses form in the aifected foci. Hyaline degeneration is also observed in portions 
of the glandular tissue, a degeneration common in other organs in diphtheria. 
"Where disintegration is not too far advanced cells with polymorphous nuclei are 
observed — evidence of an active hyperplasia. Hyperplasia with points of hemor- 
rhagic extravasation takes place also in the bronchial glands, but fewer points of 
necrobiosis occur than in the cervical and submaxillary glands, and these chiefly in 
the follicles. The lymph-ducts may contain no normal cells, and only those which 
have disintegrated nuclei along with other products of disintegration. 

Heart— The state of the heart will be in part described in our remarks relating 
to cardiac paralysis. Small extravasations of blood under the pericardial, and less 
frequently the endocardial, surface have been observed. Oertel attributes these 
hemorrhages to changes in the walls of the vessels caused by the diphtheritic virus, 
and Buhl, to nuclear proliferation in the walls and mechanical obstruction. Leu- 
cocytes in masses often occur under the pericardium and endocardium and between 
the muscular fibres. Sometimes the muscle-nuclei have undergone segmentation 
and degenerative changes. These nuclear changes occur mostly in fibres under 



DIPHTHERIA. 347 

the endocardium and around the coronary arteries. The nuclei in the muscular 
coat of the arteries are increased in size, and slight proliferation and desquamation 
of the endothelia and infiltration of the adventitia also take place. 

Mouth. Stomach. Intestines. — The diphtheritic pellicle sometimes forms in the 
cavity of the mouth, generally in small patches ; but the buccal surface is usually 
only superficially involved, except upon the tongue, where the pellicle extends more 
deeply. I have elsewhere stated that the diphtheritic exudate sometimes occurs 
upon the surface of the stomach and portions of the intestines, producing more or 
less destruction of the mucous membrane. Necrobiotic foci have been observed by 
Bizzozero and Oertel in the intestinal follicles and agminate glands, but to a less 
extent than upon the respiratory surfaces. Active cell-proliferation and disinte- 
gration and cleavage of nuclei occur, but these altered cells are mixed with others 
which are normal. The epithelium is for the most part retained and normal, and 
hyaline changes have not been observed in the gastro-intestinal vessels. The mes- 
enteric glands sometimes undergo enlargement from hyperplasia, especially when 
the intestines are affected and points of necrobiosis occur in them. For the most 
part, however, the gastro-intestinal surface is less frequently affected than other 
mucous surfaces. 

Spleen. — The diphtheritic virus reaches this organ through the blood-current. 
The spleen is swollen, so as to render its capsule tense. The pulp is soft, rising up 
through the cut surface of the capsule ; the follicles are large and prominent ; in 
the pulp are extravasations of blood and haematoidin masses, and the vessels are 
distended. Hyperplasia of the splenic corpuscles occurs, which is most marked 
around the bifurcations of the arteries, so that the reticulum is less prominent. 
The follicles are surrounded by a wide zone of the reticulated cells, among which 
we find lymphatic corpuscles, leucocytes, and large round cells. The nuclei in the 
cells undergo two changes : first, direct segmentation as in ordinary cell-division, 
and fragmentation, in which the chromatin is broken up in small, irregularly-dis- 
posed masses and the nuclear juice is susceptible of staining. In the Malpighian 
follicles either numerous epithelioid cells forirf, as mentioned by Stilling, 1 or large 
cells occur. The latter stain better by coloring reagents than the epithelioid cells, 
but less than the leucocytes. The epithelioid cells occur mostly in young patients. 
A wide zone of leucocytes surrounds and invades the follicles. The necrobiotic 
process also occurs as in other organs, beginning with nuclear disintegration, and 
when at its maximum the follicles are surrounded and loaded with the altered 
nuclei furnished by the round or epithelioid cells. Hemorrhages also occur in the 
follicles. In some protracted cases the vessels of the pulp exhibit the hyaline 
degeneration. 

Liver. — Capillary hemorrhages take place within the capsule, and occasionally 
within the parenchyma. Leucocytes occur at certain points within the liver, infil- 
trating the tissue of the organ. They occupy the interlobular spaces and do not 
exhibit nuclear changes. The hepatic cells are unchanged or they become fatty. 

Kidneys. — Albuminuria occurs from different causes, as we have stated else- 
where. Feeble heart-action, obstructed respiration, fever, and the direct irritating 
action of the diphtheritic virus upon the blood and kidneys, are sufficient causes. 
The kidneys may be normal in cases of albuminuria, or exhibit different degrees of 
parenchymatous inflammation. Hemorrhages, glomerulitis, and disseminated neph- 
ritis are common lesions observed in the kidneys in those who have died having 
diphtheritic albuminuria. Hemorrhagic points occur not only under the capsule, but 
also in the glomeruli and in and between the tubules. Cell-infiltration takes place 
around the vessels and the cells exhibit nuclear disintegration. On examining the 
glomeruli, thickening of Bowman's capsule is sometimes observed, with some albu- 
minous exudation underneath it, and epithelial proliferation and desquamation. The 
nuclei and endothelia of the glomerular capillaries are increased, and the chromatin 
and nuclear juice have undergone disintegrating and degenerative changes — results 
of inflammation. The capillaries are therefore in a degree diseased through the 
action of the blood-poison. The epithelium of the convoluted and straight tubes is 
also diseased. The epithelial cells, undergoing cloudy swelling, become detached 
from the basement membrane, fill the lumina with the necrosed product, and some 
of them escape, forming casts in the urine. Occasionally only the outer portion of 
the cell is necrosed and detached, the part adjacent to the basement membrane con- 

1 Virchoiv' s Arckiv, Bd. ciii. 



348 CONSTITUTIONAL DISEASES. 

taining the nucleus remaining in situ. Oertel says that when the entire cells are 
thrown off granular casts are formed, but if only the outer portions are lost hyaline 
casts are produced. The collecting tubes, filled with granular masses containing 
broken nuclei, cells, and epithelia, may be dilated. 

Symptoms. — Diphtheria, like scarlet fever, varies greatly in severity, 
from a form so mild that medical advice is not sought and the child is not 
even confined to his home, to a form so severe that the system is at once 
overpowered and the patient is in a critical state from the first. In general 
in the commencement of an epidemic the symptoms are more severe than 
when the epidemic influence is abating. During the continuance of the 
attack the prominent symptoms, such as arrest attention, are often dispro- 
portionate to the gravity of the case. Striking instances illustrative of this 
fact have occurred in m}- practice, the friends not supposing that there was 
any serious ailment, and not seeking medical advice until the fatal termina- 
tion was near. 

In benign diphtheria the initial symptoms are often slight, such as 
languor or lassitude, slight chilliness succeeded by fever of a light form, 
mild headache, pain or aching in the body or limbs, thirst, and impaired 
appetite. Usually some soreness of the throat is noticed in swallowing soon 
after the attack begins, and this continues. But the patient with mild diph- 
theria often continues to walk about, in the belief that he is affected with a 
slight and temporary ailment. Children with mild diphtheria in the poorer 
families are usually allowed to go abroad, and do great harm by propagating 
the disease. The symptoms in these mild cases so closely resemble those 
from a severe cold that the disease is liable to be mistaken for it. The 
slight tenderness or sensation of fulness in the fauces usually experienced by 
those old enough to express their sensations should always lead to an exam- 
ination of the fauces, when the character of the attack will frequently be 
apparent. A distinguished clergyman of the Pacific coast who fell a victim 
to this disease dreamed a few nights before he complained of his illness that 
his throat was cut. Doubtless the diphtheritic inflammation had already 
commenced, so that what seemed a forewarning had a natural explanation. 
So insidious was the commencement in this case that the disease had 
advanced beyond all hope of relief when medical advice was first sought. 

Soon after the attack commences inspection of the fauces reveals redness 
of the tonsilar surface, and this extends until the entire fauces present an 
injected appearance. After the lapse of twelve to thirty-six hours, or even 
as late as forty-eight hours, from the commencement of the disease, the 
diphtheritic exudate begins to form over the tonsils, producing the character- 
istic pellicle. Before it forms we often observe a grayish color of the prom- 
inent part of the tonsils, produced by the infiltration of the mucous mem- 
brane, and even of the surface of the tonsils, with newly-formed cells. The 
exudate may appear as points, which coalesce, forming a patch, or as a pelli- 
cle, which soon becomes thicker and at the same time firm. Its anatomical 
characters are described elsewhere. 

But in most cases, in all except of the mildest type, the initial symptoms 
are more severe than we have delineated above. The attack in the ordinary 
as well as severe form of diphtheria commences abruptly, like scarlet fever, 
without a premonitory stage and with pronounced symptoms from the first. 
The temperature rises to 102°, 103°, or even 104° F.. with corresponding 
heat of surface, thirst, languor, loss or impairment of appetite, tenderness of 
throat, etc. Delirium as well as eclampsia may occur ; but both are rare. 
The temperature ordinarily begins to fall after the second or third day in 
favorable cases, and often in those of a grave and fatal type. Subsequently 
to the third or fourth day the temperature is frequently but little elevated. 



DIPHTHERIA. 349 

The diphtheritic poison, when the system is fully under its influence, does 
not exhibit any marked tendency, like that of scarlet fever, to increase the 
animal heat. Even in profound and fatal diphtheritic blood-poisoning rap- 
idly approaching an unfavorable termination the thermometer often indicates 
nearly the normal temperature, so that the inexperienced practitioner may be 
deceived by this fact in his prognosis. A continued elevation of temperature 
considerably above the normal should lead the physician to examine for some 
complication, perhaps nephritis. 

The tongue is moist and slightly furred. Many patients vomit in the 
commencement ; and, if this symptom cease or be not repeated, it is not of 
grave import ; but vomiting occurring often, so that a considerable part of 
the food is rejected, is common in grave cases and is an unfavorable prog- 
nostic symptom. It frequently is due to uraemia. The appetite in severe 
cases is usually poor. Repugnance to food from loss of appetite and pain in 
swallowing characterize severe forms of the disease. There are no notable 
symptoms referable to the state of the intestines. The stools appear normal, 
except as they are changed by the medicines prescribed. In all cases except 
the mildest a rapid destruction of red corpuscles occurs and a relative in- 
crease of white corpuscles. Hence the anseraia, which is soon manifested by 
pallor of the surface, and which rapidly increases as the disease advances. The 
early loss of the tendon reflex has recently been brought to the notice of the 
profession. It often occurs as early as the first, second, or third day. It is 
fully treated of in our remarks relating to diphtheritic paralysis in subse- 
quent pages. It is a symptom of diagnostic value. Diphtheritic inflamma- 
tions have a marked tendency to produce hyperplasia, and consequent notable 
enlargement of the lymphatic glands in their immediate neighborhood. The 
poisonous and irritating products of the inflammation upon the surface taken 
up by the lymphatics and deposited in the adjacent glands produce in them 
tenderness, swelling, an increased afflux of arterial blood, and a rapid increase 
of the cellular elements. An inflammation both of the lymphatic ducts and 
glands arises, with more or less oedema and sometimes inflammation of the 
adjacent connective tissue. Suppuration of the glands and connective tissue, 
though it may occur, is much less frequent than in scarlet fever. 

Temperature. — There is probably no other disease in which the thermometer 
furnishes so little aid to an understanding of the case as in this, since the degree of 
fever does not sustain any fixed relation to the amount of blood-poisoning. Malig- 
nant diphtheria with profound blood-poisoning and approaching a fatal termination 
may be almost apyretic, while a benign form of the disease with but little blood- 
poisoning may commence with considerable fever (102°, 103°, or 104° F.). Fever 
in diphtheria is rather a symptom of the inflammation than of the blood-poisoning. 
Considerable elevation of temperature in diphtheria usually indicates an active 
pharyngitis, tonsilitis, laryngo-tracheitis, bronchitis, pneumonia, or nephritis. 
Therefore, although the thermometer does not aid in determining the amount of 
blood-poisoning, it enables us to form an opinion in regard to the extent and sever- 
ity of the inflammation which may be present. The thermometer is also useful 
when diphtheria occurs as a complication of another constitutional disease, as 
scarlet fever, measles, typhoid fever, since it indicates the severity of this disease. 

Such is the clinical history of diphtheria as it usually occurs, its local manifes- 
tation being primarily upon the tonsilar portion of the fauces, and extending from 
the tonsils, when the case is severe, to the posterior surface of the fauces, over the 
anterior and posterior pillars, and to the uvula. The uvula, when it is involved, be- 
comes so greatly swollen, even two or three times its normal size, as to lie upon the 
tongue, and, especially if it be covered by a pseudo-membrane, to fill up the space 
between the swollen tonsils and intercept the view of the posterior fauces. When 
the inflammation is intense and the pseudo-membrane has not yet formed or has 
been removed by solvent applications, the tonsilar portion of the fauces often pre- 
sents a grayish appearance from infiltration of leucocytes. This infiltration, if so 



350 CONSTITUTIONAL DISEASES. 

great as to obstruct the circulation, leads to necrosis ; but, as we have stated else- 
where, the necrosis of the mucous membrane is more likely to occur when it is still 
covered by the pseudo-membrane, the pseudo-membrane and mucous surface being 
incorporated with each other and being detached together. The color of the 
pseudo-membrane, at first whitish or a grayish white, becomes in a few days, in 
severe cases, a yellowish brown by the action of the atmosphere and sometimes by 
extravasation of blood. If the membrane be abundant, it is likely to have in a few 
days a musty and offensive odor, due to commencing decomposition. The constant 
inhalation of the highly poisonous gases which result is detrimental to the patient, 
and they increase the danger of infection in others. However, with the use of dis- 
infectants, now so commonly employed, the poisonous gaseous products of decom- 
position are not so common as in former times. Since the pseudo-membrane is in- 
corporated with the mucous membrane and capillaries penetrate its under surface, 
forcible detachment of the pellicle is likely to give rise to hemorrhage. Hemor- 
rhage is always a bad prognostic sign. The duration of the pseudo-membrane is 
very variable. On the average in favorable cases it is from one to two weeks. There 
are cases, however, in which the ulcerated surface is long in healing, and the ulcers 
are covered many days with the grayish-white diphtheritic exudate. In exceptional 
cases, at the close of the third or even fourth week, we occasionally observe on the 
faucial surface diphtheritic patches two or three lines in diameter, without surround- 
ing inflammation, in those who consider themselves nearly well and who would 
appear in the streets if they were allowed to do so. We will consider elsewhere 
how long enforced seclusion of the patient should be enjoined in order to prevent 
the propagation of the disease to others. 

Nares. — Usually inflammation of the nostrils occurring in diphtheria is second- 
ary to that of the pharynx. The pharyngitis has continued one or more days when 
a discharge of a thin serous appearance occurs from the nostrils. This is attended 
by swelling of the Schneiderian membrane ; and in proportion to the amount of 
swelling the respiration through the nostrils is embarrassed. As the inflammation 
continues the swelling increases and respiration is accompanied by a nasal snuffle, 
or the occlusion of the nostrils is so great that it is performed entirely through the 
mouth. The impediment to respiration in infants at the breast, so as to necessitate 
spoon-feeding, has been alluded to. The discharge is very acrid and irritating, 
causing excoriation around the entrance of the nostrils and even upon the cheeks. 
It soon becomes more viscid or less fluid than at first, and it presents a creamy 
appearance from the large proportion of pus-corpuscles. When the inflammation 
of the nares is severe, the glands around the articulation of the lower jaw usually 
undergo hyperplasia, becoming nodular and prominent, so as to be apparent not 
only to the touch, but also to the sight. 

Although, commonly, diphtheritic inflammation of the nasal surface is second- 
ary to that of the fauces, it is sometimes the primary inflammation. It may exist 
for some days before the fauces become affected, and under such circumstances the 
diagnosis is frequently not made until the disease is in an advanced stage and pro- 
found blood-poisoning has occurred. In nasal diphtheria the pseudo-membrane 
probably occurs as early as in other forms of diphtheritic inflammation, but being 
usually out of sight it is not observed in the first days or until it has extended so 
that its anterior edge can be seen on inspecting the nasal fossa. From its concealed 
position it is easy to perceive why the disease is so frequently overlooked, and a 
simple nasal catarrh is supposed to be present when there is no inflammation of the 
fauces to aid the diagnosis or it is late in appearing. 

Nasal diphtheria always involves great danger, since it is very liable to give 
rise to systemic infection from the large number of lymphatics lodged in the con- 
nective tissue of the nares. In certain severe cases accompanied by sAvelling of the 
face there is reason to think that the inflammation has entered the antrum of High- 
more — a very serious extension. It sometimes extends up the tear-duct, producing 
its occlusion, and also along the Eustachian tube. Hemorrhage sometimes occurs 
in nasal diphtheria. In those who recover the Schneiderian membrane returns 
slowly to its normal state. 

The Eye. — We have stated above that the inflammation sometimes passes along 
the tear-duct to the conjunctiva, but in other instances the inflammation occurs 
independently of this mode of propagation. Thus, if a child with simple conjunc- 
tivitis contract diphtheria, the pre-existing inflammation is very liable to assume a 
diphtheritic character, in accordance with the law already stated, that diphtheria 



DIPHTHERIA. 351 

attacks by preference surfaces that are already inflamed. I have elsewhere stated 
that diphtheria at one time entered the ophthalmic wards of the New York Found- 
lino- Asylum, and three children, under treatment for granular lids, who contracted 
the disease, had diphtheritic inflammation of the lids, with the usual pseudo-mem- 
branous exudate. The result of diphtheritic conjunctivitis, even with prompt and 
appropriate treatment, is likely to be disastrous as regards the eye. The eyelids 
become red and greatly swollen from oedema, and their under surface is soon lined 
by a thick and firm pseudo-membrane. The eye itself is the seat of chemosis. The 
pseudo-membrane upon the ocular conjunctiva is less firm, not so thick, and more 
in flakes than that upon the palpebral conjunctiva. The eye affected by this disease 
should be closely watched and promptly and efficiently treated ; but, unfortunately, 
under the most judicious treatment the cornea is likely to become hazy and slough- 
ing or ulceration follow, with total destruction of sight and perhaps prolapse of 
the iris. 

The Ear. — The ear may become inflamed by extension of the inflammation along 
the Eustachian tube from the fauces. The opening of this tube upon the faucial 
surface is small and slit-like in the child, and moderate inflammation and exudation 
are sufficient to close it. When this occurs the patient complains of pain in the 
site of the tube and in the ear. The formation of a membrane plugging the tube 
and the extension of the inflammation to the ear, producing an otitis media, add 
very much to the gravity of the case. Perforation of the drum, caries of the bones 
of the ear, and that grave disease otitis interna may occur, increasing very much 
the gravity of the case. Fortunately, this extension of the inflammation is not fre- 
quent. It does not often occur except in those malignant cases which are likely to 
be fatal from other causes. Sometimes, also, a diphtheritic otitis externa occurs. 
It is usually preceded by a catarrhal inflammation which has arisen from other 
causes and was present when the diphtheria commenced. Bezold described three 
cases of otitis externa with a diphtheritic pellicle upon the drum. 1 Moos and Callan 
have also narrated cases. 

Albuminuria. 

It is perhaps remarkable that numerous epidemics of diphtheria had been 
observed before it became known that albuminuria is a common accompani- 
ment of it. The fact that the kidneys are affected so as to give rise to albu- 
minous urine was discovered by Mr. Wade of Birmingham, England, in 1857. 
The interesting paper communicating his discovery was published in the 
Midland Quarterly Journal of Medicine, 1857. Immediately after its 
appearance the subject to which he drew attention was fully investigated in 
different countries, and in the same year Mr. James published his observa- 
tions in the Medical Times and Gazette. In the following year (1858) two 
noteworthy papers appeared on the same subject, one by MM. Bouchut and 
Empis, read before the Parisian Academy of Sciences and published in the 
Gazette des Hopitaux, and another by Germain See, and read before the So- 
ciete des Hopitaux. Since 1858 monographs and reports of cases too nume- 
rous to mention have been published, so that the literature of diphtheritic 
albuminuria is quite full. 

As to the frequency of albuminuria in diphtheria, Bouchut and Empis 
found it in two-thirds of their cases, Germain See in one-half of his, and 
Sanne in 224 cases out of 410. In New York City, where diphtheria has 
been many years naturalized or endemic, I made in the years 1875 and 1876 
daily examinations of the urine in 62 consecutive cases, and found it present 
in 24, while 38 were recorded exempt. But the proportion of cases as stated 
in my statistics is probably below the truth, for the albuminuria is sometimes 
transient, and it often occurs as a mere trace and is liable to be overlooked. 
Its duration is frequently not more than from one to three days, and in the 
majority of instances it does not continue longer than ten days ; but we are 

1 Virchoiifs Archiv, lxx. 329. 



352 CONSTITUTIONAL DISEASES. 

all familiar with cases in which it continues fifteen or twenty days, or even 
for months. 

The date of the commencement of albuminuria varies greatly in different 
cases. Perhaps the largest number of observations bearing on this point are 
those of Sanne. In 224 cases albuminuria was detected on the first day of 
diphtheria in 3, on the second day in 10, on the third day in 30, on the fourth 
day in 30, on the fifth day in 22. From the sixth day to the eleventh the 
number on each day in whom albuminuria was present for the first time 
varied from 10 to 33. After the eleventh day there were only 9 new cases, 
and after the fifteenth day only 1 new case. Hence from these statistics we 
infer that there is little danger that albuminuria will occur after the second 
week if the patient have exhibited no symptoms of it previously. 

The amount of albumen in the urine varies greatly in different patients, 
from a slight cloudiness, scarcely visible after boiling, to so large a quantity 
that it becomes semi-solid by the application of heat or nitric acid. When 
the proportion of albumen is very large, there is also usually a notable dimi- 
nution in the quantity of urine passed. In ordinary cases the percentage 
of albumen varies at different times. It sometimes disappears during one 
or two days, and we are led to think that the patient is rapidly recovering, 
but its reappearance in full quantity shows that the apparent improvement 
was due to some transient cause. " Nothing," says Sanne, " is more irregu- 
lar than the course of diphtheritic albuminuria. At one time the precipitate 
is sudden, abundant, and flocculent ; at another it commences with an opaque 
cloud, and continues with this characteristic till the time at which it disap- 
pears." Diphtheritic albuminuria differs in many respects from that in scar- 
let fever. The urine at first, when the renal disease is active, sometimes 
presents a pinkish tinge, and the microscope reveals the presence of red blood- 
corpuscles, but afterward, and in mild cases from the first, the urine exhibits 
nearly the normal appearance, even when very albuminous, in contradistinc- 
tion to its cloudy appearance in scarlet fever. The specific gravity is low, 
falling to 1010 or less, and casts, both granular and hyaline, are present. 
When the kidneys are seriously implicated the quantity of urine is usually 
notably diminished. Great diminution is a serious symptom, and it often 
precedes the fatal issue. 

In favorable cases the albuminuria does not in the average continue as 
long as in scarlet fever. The albumen may disappear from the urine in two 
or three days if its quantity has been small, and in a large proportion of 
cases it disappears within ten days ; but cases occur in which albuminuria 
continues many months, with its final disappearance and the complete restora- 
tion of the health. Thus, a boy of six years treated by me had nephritis 
following a very mild attack of diphtheria. His urine in the first weeks was 
deeply tinged by the presence of red blood-corpuscles, but its quantity was 
normal, as determined by daily examinations, and it contained nearly or quite 
the normal amount of urea. Its specific gravity was at or under 1010. 
After a time the blood-corpuscles disappeared, the urine when heated had 
its normal appearance, its specific gravity became normal, and the granular 
casts at first present disappeared. The patient was uniformly cheerful, was 
free from fever, his appetite was good, and no subjective symptoms occurred 
to indicate renal disease. Nevertheless, after the lapse of ten months a little 
albumen was still present in the urine. 

But the presence of albumen in the urine, if considerable, is an unfavor- 
able prognostic sign. Sanne states that in 233 cases of diphtheria accompanied 
by albuminuria 142 died and 91 recovered. In 160 cases in which albumi- 
nuria was absent, 63 died and 97 recovered. The statistics of others corre- 
spond with those of Sanne, so that the fact may be considered established 



DIPHTHERIA. 353 

that a larger proportion of cases of diphtheria with albuminuria perish than 
of those without albuminuria. It does not follow necessarily from this that 
the affection of the kidneys which produces the albuminuria contributes to 
the fatal result, for albuminuria is more frequent in grave cases than in those 
of a mild type. The termination in death may be due, and often is largely 
due. to other causes than the renal disease. 

Although severe and so-called malignant forms of diphtheria are more 
likely to be complicated by albuminuria than are mild forms of the disease, 
yet. as in scarlet fever, severe and fatal renal disease giving rise to albumi- 
nuria sometimes occurs in very mild cases of diphtheria. Several years ago 
I attended a child of six years with the following history : He had mild 
pharyngitis, with scarcely appreciable exudation and almost no constitutional 
disturbance. On the second day the patient seemed so nearly well that both 
the doctor and the intelligent grandmother who had charge of him did not 
think further medical attendance necessary. One week subsequently I was 
summoned to the child in haste on account of nearly complete suppression 
of urine. About one drachm was passed each time and at long intervals. 
This when heated became semi-solid. The late Prof. Austin Flint, who saw 
the case in consultation, and myself notified the family of the extreme grav- 
ity of the case and its approaching fatal termination — a prediction which was 
verified in forty-eight hours. In such rare cases, while the diphtheritic 
poison acts with great power upon the kidneys, producing a fatal nephritis, its 
influence is feebly felt in those tissues which are the usual seat of diphthe- 
ritic inflammation. Diphtheritic albuminuria is rarely attended by anasarca 
or by symptoms of ursernic poisoning. In 224 cases of diphtheritic albumi- 
nuria embraced in Sanne's statistics, dropsy occurred in only 7. Trousseau 
did not meet it oftener than in 1 case in 20. Its infrequency has been 
attributed to the fact that only one kidney or only portions of the kidneys 
have been affected, the sound portions performing sufficiently the excretory 
function. 

Oertel says : " The albuminuria of diphtheria is referable to many causes, 
of which the virus circulating in the blood is only one. Cardiac failure, 
respiratory difficulty, the febrile process, are adequate for the production of 
this symptom. The kidneys in cases where albuminuria has been present 
may be quite normal, or, on the other hand, they may exhibit varying 
degrees of parenchymatous inflammation." 1 The two common causes appear 
to be passive congestion of the kidneys, as of other organs, occurring during 
the dyspnoea of croup or from heart-failure, the albumen escaping from the 
over-distended renal veins, and parenchymatous nephritis, in which the tubules 
contain detached and disintegrating epithelial cells. In parenchymatous 
nephritis granular casts are commonly present. 

As regards prognosis, writers agree that diphtheritic albuminuria in itself 
does not tend to a fatal result in most cases, the unaffected portions of the 
kidneys, as stated above, being sufficient for the excretion of the deleterious 
products, especially the urea, whose retention in the system would involve 
danger. Therefore Sanne says " that diphtheritic albuminuria is an epi- 
phenomenon which in the vast majority of cases remains without influence 
upon the course of the disease." But cases do occur, as we have seen by 
the history related above, in which fatal albuminuria, or fatal nephritis pro- 
ducing albuminuria, does take place as a complication or sequel of diphtheria. 

Unruh in 1881 2 expressed the opinion that the albuminuria of diphtheria 
results from a simple transudation. But more exact microscopic examina- 
tions show that it is only in cases of croupal asphyxia or heart-failure that 
that degree of passive renal congestion occurs which leads to a transudation 

1 Synopsis of Oertel' s monograph, London Lancet. 2 Jahrb. fur Kinderheilk. 

23 



354 CONSTITUTIONAL DISEASES. 

of serum. When there is no obstructed respiration, and no marked weakness 
of the pulse, the albuminuria is a result and symptom of infectious nephritis. 
Prof. Bouchard 1 states that infectious nephritis, wherever the cause or source 
of the infection, is a parenchymatous nephritis. Says he : " The kidneys are 
sometimes augmented in volume and weight. Their capsule has the ordinary 
appearance and adherence. The cortical substance appears sometimes gray- 
ish, sometimes congested and sprinkled with whitish tracts. The medullary 
substance preserves its normal aspect. In kidneys thus changed microscopic 
pathological anatomy reveals integrity of the tubes of Henle, catarrhal change 
of the straight tubes, and to a considerable extent of the convoluted tubes. 
In the convoluted tubes the epithelial cells remaining in place are swollen 

and sodden together. The cellular mass is entirely granular Not only 

are the convoluted tubes obstructed by granular cells, but they are filled in 
some points by colloid matter or by blood. The glomeruli appear healthy, but 
we have seen the glomerular capsule distended with blood. In another case 
Renaut has seen it distended by colloid matter." Brault 2 has observed in 
diphtheritic albuminuria intense congestion of the capillaries of the tubules 
and glomeruli, altered epithelial cells, and transuded blood-elements indicative 
of parenchymatous inflammation. 

Paralysis. 

Another very important symptom and sequel of diphtheria is paralysis. 
It has diagnostic and prognostic value. Writers in medicine prior to the six- 
teenth century were either ignorant of diphtheritic paralysis, or they vaguely 
alluded to it when they described the extreme debility which sometimes 
accompanies or follows diphtheria. No clear and certain allusion to it has 
been discovered in medical literature until near the close of the sixteenth 
century. According to Sanne, Nicholas Lepois referred to it in 1580, and 
Miguel Heredia in 1690. Ghisi, in a letter describing the epidemic which 
occurred in Cremona on the north bank of the river Po in 1747-48, writes of 
his own son, who had paralysis in a severe form following diphtheria, " I left 
to nature the cure of the strange consequences, .... which had been re- 
marked in many who had already recovered, and which had continued for 
about a month after recovery from the sore throat and abscess. During this 
period this child spoke through the nose, and food, particularly that which was 
least solid, returned through the nares in place of passing down the gullet." 
In France also diphtheritic paralysis began to attract attention at or about 
the time when Ghisi in Italy wrote the above. Chomel in 1748 described 
two cases, following what he designated gangrenous sore throat. The first 
patient, he says, had not quite commenced convalescence at the forty-fifth day 
of the disease, having still difficulty in articulating, speaking through the 
nose, and having the uvula pendulous. In the second case the patient 
became squint-eyed and deformed, but day by day as his strength returned 
he regained his natural appearance. 

In America, in 1771, t)r. Samuel Bard, of New York, also related a case 
of this form of paralysis : A girl of two and a half years had recovered from 
a diphtheritic sore throat, and a diphtheritic pseudo-membrane upon the skin 
following the application of a blister had disappeared, when her convalescence 
was retarded by paralytic symptoms. " Whenever," says Bard, " she attempted 
to drink she was seized with a fit of coughing, yet she was able to swallow 
solid food without any difficulty. She improved, but in the second month she 
could scarcely walk or raise her voice above a whisper." 

From the time of Chomel, Ghisi, and Bard more than half a century 

1 Revue de Medecine, 1881. 2 Jour. d'Anat. et de Phys., Nov., 1880. 



DIPHTHERIA. 355 

elapsed during which diphtheritic paralysis attracted little attention, though 
Jurine and Albers alluded to it in 1809. It cannot be doubted that cases 
occurred in this long period wherever diphtheria prevailed, but it might have 
been of such a type that the paralysis was infrequent, for Bretonneau, al- 
though he was familiar with Ghisi's and Bard's writings, did not recollect 
that he had seen a case of diphtheritic paralysis prior to 1843. Although a 
close observer of diphtheria, the paralysis had not been observed by him, or 
at least had not attracted his attention, until it occurred in the person of his 
townsman, Dr. Turpin, in 1843. Twelve years subsequently, in 1855, Bre- 
tonneau had made a sufficient number of observations to convince him that 
diphtheria frequently gave rise to a peculiar form of paralysis, and in his 
writings of this year he called the attention of physicians to this fact. But 
the opinions expressed by the eminent physician of Tours did not gain gen- 
eral acceptance until his friend and admirer, Trousseau, at first distrustful of 
the existence of such a paralysis, had made a series of observations which 
fully established in his mind the theory of Bretonneau. His remarks on this 
subject, published in his Treatise on Clinical Medicine, are interesting, as 
showing how gradually important truths are revealed in medicine. He had 
seen as far back as 1833 a marked case in the service of Recamier in the 
Hotel-Dieu, and another equally severe and typical case in 1846, but it was 
a long time before he recognized this ailment as one of the effects of the 
diphtheritic poison. Says he, speaking of the cases seen in 1833 and 1846 : 
" They were a dead letter to me, yet I was acquainted with the case described 
by Dr. Turpin of Tours. Bretonneau related it to me, and said that it was 
a case of diphtheritic paralysis. The statement seemed to me incredible. I 

refused to see anything more in the case than a coincidence It was 

not till about the year 1852 that, enlightened by new cases better studied 
and better interpreted, I understood diphtheritic paralysis as Bretonneau 
understood it. From this time, whenever an opportunity occurred, I, in my 
turn, called the attention of my colleagues to this important subject." The 
clinical teachings and observations of Bretonneau and Trousseau were widely 
read, and the profession throughout the world soon recognized the fact that 
diphtheria often gives rise to a form of paralysis which, if not peculiar to it, 
is yet rare in other infectious diseases. Since these observations of Trous- 
seau were published, many others have been made and many mono- 
graphs on diphtheritic paralysis have been written by such men as Roger, 
Germain See, Herman Weber, Charcot and Vulpian, Gubler, Landouzy, Suss, 
H. von Ziemssen, A. Jacobi, and W. H. Thomson. But the nature of the 
paralysis and the manner in which it occurs are still undetermined. The fact 
that there is such a paralysis was slow in gaining acceptance in the minds of 
physicians, and so the cause and pathology of the paralysis are still not fully 
ascertained. 

Clinical History. — The statistics of different writers vary in regard to 
the frequency of diphtheritic paralysis. Probably it is different in different 
epidemics, and some observers may overlook the milder cases, which soon re- 
cover, and which are indicated by a slight impediment in swallowing and a 
slight nasal intonation of the voice. We may accept, as approximating the 
truth as regards its frequency, the following statistics of well-known and 
painstaking clinical instructors, who would be likely to detect the mildest 
forms of paralysis. In 937 diphtheritic cases observed by Cadet de Gassi- 
court, paralysis occurred in 128; 16.6 per cent, of Roger's cases of diph- 
theria had paralysis, and 11 per cent, of Sanne's cases. 

But it must be borne in mind that, since paralysis is in most instances 
post-diphtheritic, those severe cases which are speedily fatal from blood- 
poisoning or croup do not live long enough to suffer from it, and such cases 



356 CONSTITUTIONAL DISEASES. 

would be more likely to have the paralysis, if they lived, than the milder 
eases which recover. Hence it has been estimated that, if all diphtheritic 
patients lived sufficiently long, one in every four, or even one in every three, 
would exhibit paralytic symptoms. 

Time of Commencement. — In most instances the paralysis does not 
begin until the period of apparent convalescence from diphtheria and the 
pseudo-membrane has nearly or quite disappeared. Sanne says it most fre- 
quently appears from eight to fifteen days after recovery, the limit perhaps 
extending to thirty days, but he adds that it may appear from the fifth to 
the eleventh, and even as early as the second or third day of diphtheria. 
Cadet de Gassicourt states that in twenty of his cases the paralysis began 
before the disappearance of the pseudo-membrane, most frequently about the 
seventh or eighth day of diphtheria. In two it commenced on the third day, 
and once in a prolonged diphtheria it began as late as the thirty-fifth day, the 
pseudo-membrane still being present. Usually, according to my observations, 
when paralysis follows diphtheria the nasal voice and some impediment in 
swallowing are observed early in the stage of convalescence, and at a later 
period muscles remote from the fauces may or may not be affected. Dr. L. E. 
Holt exhibited to the New York Clinical Society in December, 188T, 1 a child 
of two years who had diphtheria in August and a second attack in the middle 
of October. She convalesced slowly, and in her convalescence had no paralytic 
symptoms, except a nasal voice, until December 1, when multiple paralysis 
suddenly developed. A brother of this patient also had diphtheria in October, 
moderately severe, and early in convalescence paralysis of the muscles of the 
palate began, followed by that of other muscles, but it was not until the 
middle of December that the lower extremities were paralyzed. These cases 
are examples of the usual mode of commencement and extension of the 
paralysis. 

Diphtheritic paralysis is, therefore, with few exceptions, a late symptom 
of diphtheria or a sequel ; but Dr. Boissarie 2 has related cases in which the 
paralysis was not preceded by the ordinary symptoms of diphtheria, and 
which, so far as I am aware, are unique. An officer in the police had been 
ailing two or three days ; he had a nasal voice and drinks returned through 
the nose. On inspection the velum palati was found insensible and motion- 
less, but the fauces were otherwise in their normal state. In the hospital 
alongside the barracks in which the above case occurred a young man without 
fever, redness, or swelling of the fauces had also a nasal voice and return of 
liquid food through the nose. The porter of the hospital was similarly affected, 
and the doctor stated that certain other patients in like manner presented 
symptoms of paralysis without the history of an antecedent diphtheria. Dr. 
Reynaud. called in consultation, expressed the opinion that the paralysis had 
a diphtheritic origin ; and this opinion was strengthened by the occurrence 
immediately afterward of an epidemic of diphtheria in the place where these 
cases occurred. Since paralysis is liable to occur after cases of diphtheria 
that have been very mild, as well as after those of a severe type, it is prob- 
able that these patients have had diphtheria of so mild a type that it was 
overlooked. 

The paralysis, as a rule, affects both motor and sensory nerves. Thus in 
paralysis of the velum and pharnyx anaesthesia more or less marked occurs 
of the velum, the isthmus of the fauces, and the walls of the pharynx, in 
addition to the motor paralysis. In the more severe cases anaesthesia with 
absence of reflex action occurs not only over the entire pharynx, but also 
over the epiglottis. The combination of motor and sensory paralysis should 

1 New York Medical Journal, Dec, 1887. 2 Gazette hebdomadaire, 1881. 



DIPHTHERIA. 357 

be borne in mind in studying the cause and nature of the ailment. The 
muscles affected by diphtheritic paralysis atrophy as in other forms of 
paralysis. Dr. H. von Ziemssen 1 says that such marked atrophy does not 
occur in any other disease, except in acute poliomyelitis and saturnine 
paralysis. 

The symptoms and course of diphtheritic paralysis vary according to its 
location and the muscles affected. Therefore we will sketch the clinical his- 
tory of its various forms separately, beginning with that which is first in time, 
most frequent, and least dangerous : 

1. Loss of trie Tendon Reflexes. — In 1882, Dr. Buzzard made the obser- 
vation that the knee-jerk is absent in cases of diphtheritic paralysis. Bernhard 2 
stated that loss of knee-jerk may precede other nervous symptoms, or may occur 
without other symptoms indicating impairment of the nervous system. He also 
stated a fact, now generally admitted, that the loss of knee-jerk may have diag- 
nostic value in indicating the diphtheritic nature of a pre-existing obscure disease. 
But the profession in this country had little knowledge of the loss of the tendon 
reflexes in diphtheria until Prof. R. L. McDonnell of the Montreal General Hos- 
pital read a paper on this subject before the Canada Medical Association, August 
31, 1887, and published it in the Medical News of Philadelphia in the following 
October. Dr. McDonnell's observations relate to 18 cases of diphtheria admitted 
into the General Hospital. Of these 18 patients, 10 had loss of knee-jerk at the 
time of admission, while in the remaining 8 it was present. The cases observed 
by the doctor were sufficient, he believed, to enable him to make the following 
statement : Knee-jerk in many cases of diphtheria is absent from the very first 
day of the illness. It is a noteworthy fact that in most of the cases detailed by 
McDonnell in which there was loss of the tendon reflex other forms of paralysis, 
subsequently appeared. 

Since the publication of Dr. McDonnell's paper many observations have been 
made confirmatory of his statement. At a meeting of the New York Clinical Soci- 
ety, held December 23, 1887, Dr. L. E. Holt exhibited a brother and sister of five 
and two years with multiple paralysis who had lost the knee-jerk, and the exami- 
nation of one of them showed complete loss of the plantar reflex. Since the atten- 
tion of the profession has been directed to the loss of the tendon reflexes, all observers 
admit that it is not only the earliest, but also the most frequent, of the paralytic 
symptoms, probably occurring in one-third to one-half of all cases under treatment. 
Dr. Angel Money, in a discussion before the London Clinical Society, September, 
1887, stated that he had observed an initial increase of the knee-jerk preceding its 
abolition. Dr. H. von Ziemssen remarks that, while the tendon reflexes are so often 
lost, the cutaneous reflexes are frequently exaggerated. 

The loss of the tendon reflexes, while it is the first in time of the paralytic symp- 
toms, appears also to have the longest duration. In cases of multiple paralysis it 
seems to be the last to disappear. Thus, Dr. McDonnell states that the loss of knee- 
jerk in a boy of fourteen years continued four months, and in his two sisters it was 
still present when all other symptoms of the disease had disappeared. 

2. Palatal Paralysis. — With the exception of the loss of the tendon reflexes 
the most common form of diphtheritic paralysis is that in which the velum palati 
and muscles of the pharynx are affected. This form of paralysis is revealed by a 
nasal intonation of the voice, slow speech, snoring during sleep, difficult deglutition, 
and return of liquids through the nares. As the paralysis increases in severity and 
extent, and the palato-glossus and constrictor muscles of the pharynx become para- 
lyzed, the difficulty in swallowing increases. The patient finds it necessary to throw 
his head backward in swallowing and to swallow slowly and in small amount. The 
food descends in the oesophagus by its weight, and with but little aid from the 
pharyngeal muscles. On examining the fauces we discover the velum relaxed and 
motionless, and the uvula, deprived of its tonicity, drops on the base of the tongue. 
On touching the uvula with the point of a pen or pencil it is found to be insensible. 
no reflex action occurring. Sensory paralysis occurs, as a rule, in typical cases. 
the patient experiencing no pain when the parts are pricked with a pin or other 
instrument. The fauces should be inspected and tested from day to day in order 
to determine the progress of the paralysis. In mild cases it may be limited to the 

1 KUnische Vortraye, 1887, No. iv. 2 Virchoivs Archiv, Bd. xeix. 



358 CONSTITUTIONAL DISEASES. 

velum and palate, but it frequently extends to the epiglottis and upper part of the 
larynx, so that in attempting to swallow portions of the food enter the larynx, excit- 
ing a cough. The affected muscles may regain their use in less than a week, but 
frequently from one to two months elapse before their function is restored. 

Palatal paralysis terminates favorably with few exceptions if the patients are 
otherwise in good condition, but if there be much prostration from the antecedent 
diphtheria and from the dysphagia, death may occur from inanition. Cadet de 
Gassicourt has cited two cases of death from this cause, although life was probably 
prolonged by feeding by means of an oesophageal tube introduced through the nos- 
trils. Rarely, also, death has occurred from the descent of food into the air-passages 
and the plugging of a bronchus. Tardieu and Peter have each related a case of 
this mode of death. As a chief function of the velum palati is to close the posterior 
nasal fossae during deglutition, food, especially if liquid, is liable to be returned 
through the nostrils until the function of the velum is restored. 

3. Multiple Paralysis. — This form of paralysis is commonly preceded by 
loss of the tendon reflexes. In most instances it begins with loss of power in the 
muscles of the palate, but exceptions occur Cases are reported in which the mus- 
cles of the eye, those of motion and of accommodation, are first paralyzed, the pal- 
atal muscles being unaffected or subsequently attacked. Trousseau has stated that 
in cutaneous diphtheria the first loss of muscular power is sometimes in the lower 
extremities instead of in the palate : and other observers have recorded cases in 
which multiple paralysis commenced in one or more of the extremities. Therefore 
the order of the paralytic seizures differs in different cases, and muscles are affected 
in one patient that escape in another. The degree of paralysis varies in different 
muscles. In some the loss of power is complete, while in others it is partial. "When 
the lower extremities are entirely motionless the patient frequently has considerable 
use of the upper extremities. 

Even in the severest cases many groups of muscles entirely escape. Therefore 
I prefer the term multiple paralysis to the term general paralysis employed by some 
writers to designate this form of the disease. 

Trousseau speaks of what he designates the mutability of diphtheritic paralysis. 
He says the paralysis which occupies one limb disappears in this limb to manifest 
itself in another. ' ; The numbness, for example, which the patient has been experi- 
encing in one leg will suddenly cease, and become greater in the other leg. To-day 
the right hand will not give a dynamometric pressure of more than ten to twelve 
kilogrammes, and to-morrow its power will have augmented, while that of the left 
will have diminished ; then the parts which were first affected are a second time at- 
tacked and become more affected." Even the dysphagia may vary on different days, 
as Cadet de Gassicourt has stated. He relates the case of a child of three and a half 
years in whom the velum palati suddenly resumed its function : the head, which 
had dropped from paralysis of the muscles of the neck, became erect, the patient 
was able to sit, and the upper extremities recovered their power, but the improve- 
ment was of short duration, the paralysis returning as at first. These sudden and 
unexplained variations in the degree of paralysis resemble, says Trousseau, the 
mutability of paralysis in hysteria. Among the most noteworthy of the paralyses 
resulting from diphtheria are those pertaining to the eye. The media and retina 
are unaffected, but the levator palpebrae, the muscles of accommodation, and the 
motor muscles of the eye are paralyzed in certain patients, so as to cause dropping 
of the eyelids, strabismus, and indistinct vision. In addition to the muscles already 
mentioned, various muscles of the trunk, of the neck, the sphincter ani, and the 
sphincter vesicae are sometimes paralyzed, producing deformity and incontinence of 
urine and feces. The paralysis of the muscles of accommodation is usually such 
that patients become presbyopic, seeing distinctly distant, but not near, objects. 

The muscles of the face are also occasionally paralyzed. Many observers have 
related cases of facial hemiplegia. When general paralysis of the facial muscles 
occurs — fortunately, a rare event — whatever the mental state, however great the 
excitement, the features are entirely devoid of expression : the aspect is dull and 
idiotic ; the face is flabby and motionless : the lids and lips droop : saliva flows from 
the mouth ; and speech is slow and difficult. At the same time, the mental faculties, 
though deprived of the usual mode of expression, are sound and active. 

But the most accurate idea of the symptoms of multiple paralysis can be 
imparted b} T the narration of a case, and I select for this purpose the graphic de- 
scription of this form of paralysis published by Dr. C. W. Fallis in the Medical 



DIPHTHERIA. 



359 



Summary for January, 1888. He describes the ailment as it occurred in his own 
person, as follows : " About three weeks after the subsidence of the disease [diph- 
theria] the paralytic symptoms began to show themselves. Impaired vision was 
the first trouble noticed, inability to accommodate the eyes to near objects, and in 
taking up the paper to read one morning I found I could scarcely see a word, and 
soon after, although distant objects could be seen as well as ever, high-power glasses 
were required to read any kind of print. Double vision was noticed afterward. At 
about the same time numbness of the tongue was felt ; the muscles of deglutition 
became paralyzed, so that swallowing was attended with strangling and regurgita- 
tion of food through the nose. There was a rapid pulse, 120 to the minute, show- 
ing that the pneumogastric was involved. Weakness of the limbs, causing a stag- 
gering gait, appeared: fingers became weak and numb, so that small objects could 
not be picked up. the symptoms becoming worse and worse as the disease progressed. 
The muscles of the left side of the face became affected with all the symptoms of 
facial paralysis from organic diseases. Motion became more and more impaired, 
till I could neither stand nor walk, and when at the worst I was perfectly helpless, 
could not feed myself, had to be lifted from chair to chair, turned in bed, and could 
not even lift my hand to my head or throw one limb over the other. Sensation was 
so impaired that hands and feet felt like lifeless weights, and in the dark 1 could not 
tell whether my feet were on the floor or not. The muscles of respiration were at 
no time affected to such an extent as to render breathing difficult, and the power of 
perfect speech was retained. Paralysis of the bowels necessitated the use of warm- 
water injections to promote their action. Some of the symptoms abated, while 
others became more aggravated, those first to appear being generally the first to 
subside : however, the smaller-sized muscles recovered rapidly, while the large 
fleshy ones were more tardy in reaching their normal state, the facial paralysis last- 
ing but a few days, while locomotion was either labored or impossible for many 
weeks. The course of the disease from the beginning to the worst stage was about 
nine weeks, when it remained stationary for two weeks. Improvement was at first 
very slow and tedious, but after I could walk a little it was much more rapid, and 
by the fifteenth week, with the exception of some weakness, I was well." 

Multiple paralysis not infrequently continues from two to six months. As 
might be expected, the prognosis is less favorable when the paralysis is multiple 
than when it is restricted to the velum and pharynx. In 13 cases observed by 
Cadet de Gassicourt, 6 died. 

4. Cardiac Paralysis (the cardiopulmonary paralysis of certain French 
writers). — In cases of the first, second, and third forms of paralysis which have 

been considered above the vital organs 
Fig. 47. are not directly involved. These paral- 



r 



Fig. 48. 



Diphtheritic paralysis. Fibres from 
a paralyzed muscle. Recent prepara- 
tion. Granular and fatty degeneration. 




Changes in the fibres of the anterior roots, 
picro-carmine preparations. (After Meyer; 
Virchow's Archiv, Bd. 85.) 

a, overgrowth of the protoplasm and nuclei 
of the sheath ; the axis-cylinder is continu- 
ous, although the medullary sheath is inter- 
rupted for a short distance. 

b, accumulation of granule masses, in 
places interrupting the axis-cylinder, frag- 
ments of which can be seen between the 
globules of myelin. 

C, a fibre in which the degenerating white 
substance ceases suddenly, leaving the axis- 
cylinder only covered with the thickened 
sheath. 



360 



CONSTITUTIONAL DISEASES. 



yses, however inconvenient they may be, are not directly fatal. The paralysis which 
we are about to consider presents a very different clinical aspect, inasmuch as the 
organs affected are among the most important in the system, a serious impairment 
of their functions rendering death inevitable. 

Physicians who have had experience in the treatment of diphtheria have met 
cases in which symptoms, usually of sudden development, indicated dangerous 



Fig. 49. 




Interstitial and parenchymatous changes in the phrenic nerve : osmic acid preparations. 
(Meyer, loc. cit.) 

The three separate fibres show degeneration of the nerve-fibres (segmentation of the myelin, 
etc.), with some increase of the nuclei. 

The lower group of fibres is from one of the nodular swellings on the same nerve, and 
shows, in addition to degeneration of the fibres, considerable increase in the interstitial tissue. 



heart-failure. Perhaps the patient has been gradually improving, the pseudo- 
membrane has nearly or quite disappeared, the temperature is not far from normal, 
the swallowing is better and more nutriment is taken, the family are cheerful in the 
prospect of a speedy recovery, and the physician expects soon to discharge the 
patient cured. Suddenly the scene changes. The pulse becomes feeble and ab- 
normally slow or rapid — it is usually at first slow and subsequently rapid — the 
respiration is superficial, and the surface becomes pallid, often slightly cyanotic. In 
the more favorable of these cases the patient may rally by active stimulation, and 
perhaps he eventually recovers, or after some hours or a day of comparative com- 
fort he succumbs to a return of heart-failure. There is no other disease in which 
these sudden, unforeseen, and fatal attacks of heart-failure occur so frequently as 
in diphtheria. There is no other disease in which physicians are so frequently 
deceived in their prognosis for various reasons, but largely on account of the occur- 
rence of these unexpected attacks of heart-weakness. 

But a clear and accurate idea of the clinical history of these cases of sudden 
heart-failure can be best imparted by the relation of typical cases. For this pur- 
pose I will briefly narrate cases occurring in the hospital service of one of the most 
trustworthy clinical teachers of the present time, M. Cadet de Gassicourt, though I 
believe that all physicians who have been several years in practice where diphtheria 
is prevailing can recall to mind cases equally striking and typical. I select his 
cases on account of the completeness of his records : 

A child of two years entered Cadet de Gassicourt's service on January 3d with 
diphtheritic pharyngitis of ten days' continuance. The tonsils were large, still 
covered with pseudo-membrane, and the submaxillary glands were also enlarged. 
He had no laryngeal symptoms and his urine was without albumen. On the follow- 
ing day the velum and pharyngeal muscles were slightly paralyzed, the speech 
nasal, and deglutition moderately embarrassed. He was quiet during the night of 
January 4th and in the morning of the 5th, but at ten a. m. he became chilly, his 
face and extremities feebly cyanotic, and slight dyspnoea and dilatation of the alse 
nasi were observed. His pulse, at first abnormally slow, became rapid ; he was 






DIPHTHERIA. 361 

agitated, uttered loud screams of distress, and fell back cyanotic and dead. The 
death-struggle did not occupy more than one minute. Another infant, also two 
vears of age, entered the same service, having diphtheritic pharyngitis of two days' 
continuance. The fauces presented the usual red appearance, the tonsils were 
swollen and covered with a thick exudate, but there was no albuminuria nor croupi- 
ness. Two days later the pseudo-membrane had diminished, but the velum palati 
was paralyzed. On the following day the general appearance was satisfactory and 
the pseudo-membrane had still further diminished. At eight p. m. the infant was 
suddenly seized with vomiting, accompanied with great dyspnoea, rapid pulse (160), 
and a cyanotic hue of the face and extremities. He was restless and uttered cries 
of distress. Two hours later he screamed loudly, raised himself in bed, and fell 
back dead. A child of five years was admitted with diphtheritic pharyngitis of 
two days' continuance, having enlarged tonsils covered with pseudo-membrane, and 
enlarged cervical glands, but without cough or albuminuria. Seven days later, 
the ninth of the disease, the pseudo-membrane had disappeared, but the velum 
palati was paralyzed. On the following day there was little change, except occa- 
sional vomiting, but the general state was good and sleep tranquil. At seven a. m. 
on the following day, the eleventh of the disease, after a calm night, the child 
uttered two or three cries, the pulse became rapid, the respiration embarrassed, the 
features, extremities, and finally the entire surface, cyanotic, and at eight a. m. 
death occurred quietly. 

The similarity of these three cases is apparent. Paralysis of the velum and 
palate had continued in the first case eighteen hours, in the second case thirty-six 
hours, and in the third case forty-eight hours, when suddenly the heart and lungs 
were greatly embarrassed in their functions, and death occurred within one hour 
from the commencement of the severe symptoms. The agitation, repeated cries of 
distress, and the shrill cry that preceded death indicated extreme suffering. 

Severe pain, preecordial, epigastric, or abdominal, is present in some if not in 
most of these cases of sudden heart-failure, as we shall see from others presently to 
be related. It was probably experienced by these three patients, who were too 
young to express clearly the subjective symptoms. 

Gombault made a minute microscopic examination of the affected organs in 
these three cases after the tissues had been properly hardened by chemical agents. 
In one of the cases he examined the pneumogastrics and myocardium, and both 
were found in their normal state. As regards the nervous centres, the anatomical 
changes were alike in all three. In the spinal cord lesions were found at the origin 
of the anterior roots of the spinal nerves, characterized by fragmentation of the 
medullary substance in the nerve-fibres, numerous granules and minute globules 
appearing in this substance and occupying its place. 

In addition to this, undue swelling of the axis-cylinders was observed. In the 
three cases the gray substance in the anterior cornua had undergone a sort of rare- 
faction, the microscopic sections being more transparent and the elements in the sec- 
tion being wider apart than in the normal state. No meningitis or injury of the 
blood-vessels was observed in the spinal columns, but numerous nerve-cells were 
deprived of their prolongations. The medulla oblongata, the centre and source of 
the nervous supply to the heart, lungs, and stomach through the pneumogastrics, 
was also carefully examined in the three cases. Nothing abnormal was observed 
in this organ, except small masses of leucocytes in the vessels. The substance of 
the medulla oblongata and the nerve-fibres constituting the roots of the pneumo- 
gastrics seemed healthy. The small masses of leucocytes in the blood-vessels were 
not sufficient to obstruct the circulation, and the appearance of the blood-corpuscles 
was normal. Hence, in the opinion of Gombault, the small aggregations of leuco- 
cytes in the vessels had no effect on the innervation of the thoracic organs derived 
from the medulla. The points of special interest in the microscopic examination 
of the three cases were the apparently healthy and normal state of the pneumogas- 
trics and myocardium in the one case in which they were examined, and of the me- 
dulla oblongata in the three cases, while the gray matter of the spinal cord, which 
has no immediate nerve-connection with the heart, showed marked degenerative 
changes. 

The above are striking examples of sudden and fatal heart-failure occurring 
during apparent convalescence, when the symptoms of diphtheria appeared to be 
abating, with the exception of the paralysis of the velum and palate. The follow- 
ing cases presented a clinical history in some respects different : A child of eight 



362 CONSTITUTIONAL DISEASES. 

years had been under treatment for diphtheria since February 9, 1883. On Feb- 
ruary 20th the membrane had disappeared, but slight paralysis of the velum and 
left upper extremity was observed, and the urine contained a little albumen. At 
three p. m. she was seized with severe abdominal pains, followed by vomiting, slow 
respiration, slow and feeble but regular heart-beat, imperceptible pulse, coolness of 
surface, and cyanosis. These symptoms increased, and at half-past six p. m. death 
occurred. The clinical history differed from that in the three cases related above in 
the fact that there was no agitation or moaning at the close of life, and that the 
heart-beat remained abnormally slow unless during the last moments. In another 
case paralysis of the velum and palate began on the third day of diphtheria, while 
the pharyngeal and nasal inflammations were in full activity. The urine was slightly 
albuminous. Three days subsequently, in the morning, the muscles of the nucha 
and right shoulder were paralyzed. At two p. m. the child complained of violent 
abdominal pains, followed by nausea and vomiting. The vomiting was partially 
relieved, but dyspnoea and a rapid heart-beat followed. The cyanosis increased until 
it extended over the entire surface, and death occurred three hours after the com- 
mencement of symptoms referable to heart-failure. A boy of five years had diph- 
theritic croup, for which tracheotomy was performed and the canula inserted. He 
subsequently did well for a time, but afterward lost his appetite. On the eleventh 
day of the disease he had paralysis of the velum and palate. On the twelfth and 
thirteenth days the disease seemed to be stationary and the child was quiet. Sud- 
denly, at seven p. m. on the thirteenth day, multiple paralysis occurred. An hour 
later the muscles of the nucha, the arms, and both sides of the trunk were paralvzed 
and the head dropped. At seven a. it. on the following day vomiting, dyspnoea, 
cyanosis of the face and extremities, and a very rapid pulse occurred. The asphyxia 
increased, the pulse grew more feeble, the surface cool, and death took place three 
hours later. 

Cases like the above are not infrequent in severe epidemics of diphtheria, but in 
some instances the loss of power in the heart occurs more gradually. A boy of 
twelve years had diphtheritic pharyngitis from which he was apparently convales- 
cing. Some days after the disappearance of the inflammation the velum palati and 
muscles of the pharynx were paralyzed. Then succeeded paralysis of the muscles 
of the nucha, of the muscles of accommodation, and of those of the upper and lower 
extremities. The march of the paralysis was for a time progressive. Then it seemed 
to recede, but the improvement did not continue. One month from the commence- 
ment of diphtheria the child uttered plaintive cries, became motionless as if from 
general paralysis, and a state of asphyxia slowly occurred, accompanied by cyanosis. 
During the following night the patient lay in a stupor, and on the ensuing morning 
the features presented a cadaverous and slightly cyanotic hue. the extremities were 
cool and blue, the tongue pallid, moist, and of a normal warmth, the respiration 
hurried and without auscultatory signs of disease, the pulse feeble and rapid (148). 
Finally, the sphincters were paralyzed, the urine and feces escaping involuntarily. 
Within ten minutes after the above notes were written the patient died of cardiac 
paralysis. The feature of special interest in this case was the long continuance of 
multiple paralysis when the cardiac and pulmonary symptoms occurred. 

Sudden heart-failure in diphtheria is usually fatal, but recovery is possible. 
Cadet de Gassicourt in his large clinical experience met 1 recovery to 1-4 deaths. 
This case is interesting, since the heart-failure preceded the palatal and other forms 
of paralysis, instead of being preceded by them, as is ordinarily the case. Twenty 
days after the commencement of diphtheria, and when in apparent convalescence, 
the patient was seized with extreme pain in the precordial region, attended by a 
fall of pulse to 42. He had cold sweats, rigors, and vomiting. In one and a half 
hours these symptoms abated. Three days subsequently another similar attack 
occurred, and subsequently two others, but less severe than the first. On the 
tvrenty-eighth day from the beginning of diphtheria and eight days after the syn- 
copal attacks paralysis of the velum and pharynx began, soon followed by paralysis 
of the vocal cords, of the muscles of accommodation, and of those of the extremities, 
which continued three months, when recovery was complete. Cases of recovery from 
sudden and alarming symptoms of prostration have also been related by Sanne, 
Billard, and others. 

What is the cause of this sudden loss of power in the heart in diphtheria, occur- 
ring usually during apparent convalescence? Does it result from disease in the 
muscular structure of the heart, from thrombosis or ante-mortem clots in the cavities 



DIPHTHERIA. 363 

of the heart, or does it result from disease of the central organ of innervation, the 
medulla oblongata, or from disease and deficient conducting power in the important 
nerve which controls the heart's action, the pneumogastric, or in the branches which 
this nerve supplies to the heart as well as the lungs and the stomach ? — for these 
three organs appear in most instances to be affected simultaneously. 

The theory of MM. Bouchut and Lagrave which attributed sudden heart-failure 
to endocarditis has not been sustained by recent observations, and does not appear 
to be tenable. 

Weakening of the heart's action in diphtheria, with sudden death as a conse- 
quence, has with more probability been attributed to granulo-fatty degeneration in 
the muscular fibres of the heart consequent upon a prolonged and severe diphthe- 
ritic attack. Oertel says : k ' When the general disease lasts long and is very intense, 
and especially in cases in which death is caused suddenly by paralysis of the heart, 
the muscle appears pale, soft, friable, broken by extravasations of blood, and on 
microscopical examination most of its fibres are seen to be in an already advanced 
stage of fatty degeneration.' 71 Such degenerative changes, if occurring in a con- 
siderable proportion of the muscular fibres of the heart, would inevitably render 
the contractile power of this organ feeble and perhaps inadequate. Still, if we 
regard it as a cause of sudden heart-failure, it can be regarded as such in only a 
relatively small number of instances, for in most cases the weakening of the power 
of the heart is sudden and during convalescence — at a period, therefore, when 
degenerative changes are not likely to occur. In most of the recorded cases the 
contractile power of the heart does not appear to have been notably weakened pre- 
vious to the attack of heart-failure, as it would probably have been were degenera- 
tive changes in the myocardium the sole or chief cause. The clinical history is as 
if the heart were suddenly overpowered by an agent of rapid — never slow — devel- 
opment. Moreover, in typical cases of sudden heart-failure the microscope some- 
times reveals a healthy myocardium, as in one of the cases related above. We 
must look, therefore, for some other cause, although admitting that degenerative 
changes in the muscular fibres of the heart, when present, contribute to a weakened 
action of this organ. 

In searching for the cause of sudden heart-failure in diphtheria we must note 
the fact that, as a rule, in typical cases it is preceded by palatal and often multiple 
paralysis. The paralysis has continued for a time, extending perhaps from one 
group of muscles to another, when suddenly the heart passes under some powerful 
influence which restricts and overpowers its action. The theory of deficient inner- 
vation or a true cardiac paralysis appears most tenable under the circumstances. 
It affords the most satisfactory explanation of those unfortunately not infrequent 
cases in which death suddenly occurs during apparent convalescence from diphtheria, 
when the symptoms are fast disappearing, with the exception of the palatal or other 
paralysis. It affords best of all the theories an explanation of the occurrence of 
sudden death from heart-weakness in those obscure cases which have puzzled phy- 
sicians — cases in which the post-mortem examination has revealed an apparently 
healthy state of the heart. The theory of an arrested or deficient innervation of 
the heart also furnishes an explanation of the occurrence of concomitant symptoms 
in these cases of sudden heart-failure — such symptoms as vomiting, epigastric pain, 
and dyspnoea or irregular respiration ; for the heart derives its innervation from the 
same source as the lungs and the stomach — that is, through the pneumogastric. 
For the reasons now given we feel justified, in our classification of the forms of 
diphtheritic paralysis, to make a distinct class having the designation cardiac 
paralysis, or to adopt in our language the French expression, cardio-pulmonary 
paralysis. 

Paralysis: Its Cause. — The four forms of diphtheritic paralysis — first, 
the abolition of the tendon reflexes, the most common, the earliest, and the 
least dangerous of all ; secondly, palatal paralysis, which may occur as early 
as the third day of diphtheria, but is most common during its later stages. 
or in the period of convalescence ; thirdly, multiple paralysis, in which 
various muscles throughout the system are paralyzed ; and, fourthly, car- 
diac paralysis, the most dangerous of all — probably are produced by the 

1 Ziemsserfs Cyclopcedia, vol. i. 



364 COXSTITUTIOXAL DISEASES. 

same cause and have the same pathology in most instances. We may, there- 
fore, in the following pages, in studying the cause and nature of diphtheritic 
paralysis, regard the various forms which it exhibits as manifestations of one 
disease. What is true of cardiac paralysis as regards its cause and nature 
we may assume to be true in reference to palatal and multiple paralysis, and 
even the abolition of the tendon reflexes. The most dangerous and fatal 
paralysis, the cardiac, is, as we have stated above, in nearly all patients asso- 
ciated with the milder forms, showing that the same cause or causes are 
operative at the same time in the individual. 

G-ubler, in his memoir published in 1860-61. attributed paralysis of the 
velum and palate to disease of the terminal nerves produced by contiguity 
or propagation from the inflamed fauces ; and he held that the same injury 
of the nerves and paralysis might result from any anginose inflammation 
if severe enough. But this theory was short-lived, for physicians soon per- 
ceived that it was inadequate to explain the occurrence of paralysis at a 
distance from the inflamed surfaces ; and palatal paralysis sometimes occurs 
after cutaneous and other forms of diphtheritic inflammation in which both 
the fauces and the nares have entirely escaped and remained healthy. 

Trousseau, impressed with the inadequacy of Gubler's theory, directed 
his attention to the nervous centres. He was led to believe, from the fact 
that the paralysis usually terminates favorably, and because in certain fatal 
cases he was unable to discover any lesion sufficient to produce the paralysis 
in the brain, spinal cord, or meninges, that it did not occur from any struc- 
tural change in the nervous system. Trousseau, an unsurpassed clinical 
observer, was not a microscopist, and being unable to discover any anatomi- 
cal cause of the paralysis, he relates the case of the crew of a vessel who 
were paralyzed by eating an eel which contained some poisonous ingredient, 
and. after alluding to instances of paralysis resulting from smallpox, typhoid 
and typhus fevers, and cholera, continues : " Well. then, diphtheritic paralysis 
belongs to the same category : its real cause is the poisoning of the system 
by the morbific principle which generates the malady on which the paralysis 
depends, and in regard to the mode of action of which in producing the 
paralysis we shall always perhaps remain in ignorance." 

Since the time of Trousseau many eminent pathologists have endeavored 
to discover the anatomical characters and elucidate the nature of diphtheritic 
paralysis by patient and thorough microscopic examinations. We have already 
detailed the microscopic appearance in Cadet de Gassicourt's three memor- 
able cases. In 1862, Charcot and Yulpian stated that they had examined 
the nervous filaments in the velum palati paralyzed by diphtheria, and found 
certain of them entirely free from medullary matter, granular bodies occupy- 
ing its place ; but partial degeneration is more common. In some of the 
fibres the medullary matter was intact. Lionville in 1872 stated that he had 
found degenerative changes in the phrenic nerve of a patient who had died 
of asphyxia following an attack of diphtheria. The contents of certain of 
the fibres constituting this nerve were amorphous, filled with granular bodies 
instead of the normal nerve-substance. Leyden in 1872 discovered lesions 
in the peripheral nerves and in the central organ upon which he based his 
theory of an ascending neuritis. Roger and Damaschino in 1875 examined 
the nervous system of four children who had died of diphtheritic paralysis, 
and found atrophy of the nerve-fibres in the peripheral nerves. The medul- 
lary matter appeared granular in certain points, and in others it had entirely 
disappeared, while the axis-cylinder was not notably altered. 

Such observations, to which others might be added, have fully established 
the fact of peripheral nerve-lesions, such as would be likely to result from a 
neuritis, in the paralysis of diphtheria ; but it must be borne in mind that 



DIPHTHERIA. 365 

the various observers, while they report degenerative changes in certain of 
the nerve-fibres or tubes in the peripheral nerves of the paralyzed part, also 
state that others in the same nerves were to appearance normal and capable 
of performing their function. Such are the facts upon which the theory 
that diphtheritic paralysis is caused by peripheral nerve-lesions, a peripheral 
neuritis, is based. 

Prognosis. — The prognosis of diphtheria, like that of scarlet fever, varies 
greatly in different cases according to its type. In some epidemics a large 
proportion of the cases are mild and recovery occurs with simple treatment. 
Between the mild and the most severe cases, attended by profound blood- 
poisoning, there is every grade of severity. Cases that are apparently mild 
in the beginning and seem likely to recover with simple measures sometimes 
become severe, dangerous, and even fatal. On the other hand, cases that set 
in with severity may become modified and end favorably with simple treat- 
ment. So variable is the type of diphtheria that in certain epidemics or 
localities a large proportion recover, as many even as 90 or 95 per cent., 
while in other epidemics or localities the proportion that perish is much larger. 

The prognosis is usually favorable when the inflamed surface and pseudo- 
membrane are of little extent, the fever and swelling moderate, and the 
neighboring lymphatic glands and underlying connective tissue but little 
involved. In many such cases, as we have seen from the description given 
above, the patient remains in good general health or feels but slightly indis- 
posed. On the other hand, if the inflamed surface be extensive, the pseudo- 
membrane deep-seated and exhaling an offensive odor, while the adjacent 
lymphatic glands are markedly swollen, the patient will probably perish. 
Nasal diphtheria, which is commonly present in severe cases, and which pro- 
duces an offensive, irritating, and highly infectious discharge, always involves 
great danger. It is likely to give rise to systemic infection, since the sub- 
mucous connective tissue of the nostrils contains numerous lymphatics, which 
take up the poisonous products and convey them to every part of the system. 
If, while the local disease is severe and extensive, the breath and exhalations 
become offensive and the countenance and surface generally begin to have a 
dusky, pallid hue, profound blood-poisoning has occurred and the patient will 
probably die. 

Physicians of experience are guarded in the expression of a favorable 
prognosis in diphtheria, since there is no other disease in which the prog- 
nostic signs on which a favorable prediction is based are so likely to be 
fallacious. We hear much in medical circles of the deceptive character of 
diphtheria. Errors in expressing a favorable prognosis, of which even phy- 
sicians of ample experience complain, is largely due to the fact that diphtheria 
terminates fatally in several different ways. Death may occur from — 

1. Diphtheritic blood-poisoning — systemic infection by the diphtheritic 
toxine. 

2. Septicaemia, produced by absorption from the under surface of the 
decomposing pseudo-membrane or from gangrenous tissues. Very commonly, 
in addition to the Klebs-Loeffler bacillus, cocci are present, which, with the 
toxines generated by them, enter the lymph-channels and blood-vessels of 
the neck. Considerable tumefaction of the neck therefore seldom occurs in 
diphtheria without manifest symptoms of septicaemia, and it is to be regarded 
as a sign of its presence. 

3. Diphtheritic croup or pseudo-membranous laryngo-tracheitis. a most 
important disease, and fully treated of in the proper place. 

4:. Uraemia or diphtheritic nephritis, also one of the most important of the 
local maladies pertaining to diphtheria, and produced by the action of the 
diphtheritic poison. 



366 CONSTITUTIONAL DISEASES. 

5. Sudden heart-failure. The action of the heart becomes feeble from 
granulo-fatty degeneration of its muscular fibres and degenerative changes 
in the pneumogastric and in the gray tracts from which the pneumogastric 
arises. 

6. Suddenly-developed passive congestion and oedema of the lungs, prob- 
ably due to feebleness of the heart's action or to paralysis of the respiratory 
muscles. Death sometimes occurs, apparently from this cause, during the 
period of supposed convalescence and when the visits of the physician have 
been discontinued. Thus, in a case in my practice symptoms of oedema pul- 
monum (abundant moist rales in both sides of the chest and embarrassed 
respiration) suddenly occurred nearly one month after the disappearance of 
the faucial pseudo-membrane and inflammation. The urine, which had con- 
tained considerable albumen during the active period of the malady, had for 
some time shown no trace or but slight trace of this principle by the proper 
tests. By active stimulation these symptoms entirely disappeared in a few 
hours, and the heart's action seemed normal, except that it was a little weak- 
ened. On the following day the symptoms reappeared, and death occurred 
before I was able to reach the house. 

That physician is obviously least likely to err in prognosis who recognizes 
the fact that patients are liable to perish in any of these different ways, and 
carefully examines in reference to all the conditions which involve danger. 
3Iany physicians, as I have had the opportunity to observe, are remiss in not 
examining more frequently the urine of diphtheritic patients ; for there is 
often a large amount of albumen with granular casts in the urine in diph- 
theria, indicating a poisonous quantity of urea in the blood, and yet the 
appearance of the urine to the naked eye is normal. 

Among the symptoms which render the prognosis unfavorable are repug- 
nance to food, vomiting, pallor of countenance, and general anasmia. with 
progressive weakness and emaciation, indicating blood-poisoning ; a large 
amount of albumen, with casts, in the urine, showing urasmia, to which the 
irritability of the stomach is often due ; an abundant irritating discharge of 
muco-pus from the nostrils or occlusion of them by membranous exudation 
or inflammatory thickening, showing that the Schneiderian membrane is 
seriously involved ; hemorrhage from the nostrils, buccal cavity, or fauces, 
showing an altered state of the blood or of the walls of the capillaries, or 
plugging of the capillaries by masses of microbes or leucocytes. Diphtheritic 
laryngo-tracheitis, or pseudo-membranous croup, largely increases the aggre- 
gate of deaths from diphtheria, whether it be treated by improved inhalations, 
intubation, or tracheotomy. Some of the above symptoms have been present 
in most of the fatal cases which I have observed. On the other hand, the 
prospect of recovery improves in proportion to their absence. 

Preventive Treatment. — Diphtheria is so highly contagious, and when 
epidemic is so likely to spread from one household to another, and its severe 
forms are fatal in so large a proportion of cases, that preventive measures are 
of the greatest importance. The area of contagiousness of diphtheria is small. 
Dr. Lancry cites cases to show that it is limited to a few feet. Dumez also 
relates an instance showing that the contagious area is of small extent. In 
a school the boys and girls on the same floor were separated by an open space 
a few yards wide. Diphtheria prevailed among the girls, but did not affect 
the boys. In this respect, as in so many others, diphtheria resembles scarlet 
fever, and is unlike pertussis and measles. 

The most efficient method of preventing diphtheria is the isolation and 
disinfection of patients, the prompt and thorough disinfection of the apart- 
ments in which patients have been treated and of the bedding and furniture 
in these apartments, and the exclusion or prevention of all noxious gases, 



DIPHTHERIA. 367 

especially those ascending from the sewers and from filthy accumulations of 
all kinds. 

Br. H. B. Baker of Michigan has published statistics showing that in 102 
outbreaks of diphtheria the average number of cases where disinfection and 
isolation, one or both, were neglected was 16, and the average deaths 3.26, 
while in 116 outbreaks in which isolation and disinfection were enforced the 
average number of cases per outbreak was 2.86, and the average deaths .66. 
Therefore these precautionary measures prevented 13 cases and 2.57 deaths 
for each outbreak ; in the total, 1545 cases, 298 deaths. These statistics 
relate to only one year. 1 

Loeffler has ascertained in his experiments with the Klebs-Loeffler bacillus 
that solutions of the following substances in the strength mentioned are suffi- 
ciently germicidal to sterilize cultures: corrosive sublimate, 1 part to 10,000 
or even 15,000 ; cyanide of mercury, 1 part to 8000 or 10,000 ; chlorine water, 
1 part to 1100 ; thymol 1 part to 500, with 20 per cent, of alcohol. Loeffler 
advises that physicians, nurses, and others exposed to diphtheria gargle every 
three or four hours with one of these substances. Frequent bathing of the 
hands, face, and head with a disinfectant, and frequent change and disinfec- 
tion of the clothes worn in the sick-room, should also, says Loeffler, be enjoined. 
Graucher of Paris, who has had a large experience in the treatment of diph- 
theria expresses the opinion in a recent paper that in nearly all instances 
diphtheria is communicated by infected articles of clothing or furniture. He 
also thinks that there is evidence that the non-pathogenic bacillus often pres- 
ent upon the healthy buccal surface may, under exceptional circumstances, 
become pathogenic so as to cause diphtheria. Except under such circum- 
stances, he believes that the spread of diphtheria may be prevented by the 
prompt and thorough disinfection of the sick-room and infected articles and 
persons. He states that in a ward set apart for diphtheritic patients in Paris, 
among 17-41 admitted during a series of years, 153 were found not to have 
diphtheria, and yet by the disinfection employed not one of them contracted 
the disease. In a moist atmosphere the Klebs-Loeffler bacillus is killed at a 
temperature of 60° C. (140° F.), but in a dry atmosphere a temperature of 
at least 98° C. (208° F.) is required to destroy it. Graucher has prevented 
the spread of diphtheria in the hospital ward by the following prophylactic 
measures : A metallic screen surrounds the bed ; all articles used by the 
patient, as spoons, forks, or napkins, are disinfected by being placed in boiling 
water containing sodium carbonate, 1 ounce (31 grammes) ; boiling water 1 
pint (480 grammes). The bedding and all clothes used are disinfected by 
heat, and the floor, bedstead, and walls are washed with the corrosive-sublimate 
solution. Nurses and medical attendants wear blouses that are disinfected 
by heat each day, and they wash themselves with a solution of corrosive sub- 
limate or a 5-per cent, solution of carbolic acid. 

That the schools and places of public resort for children are largely instru- 
mental in disseminating diphtheria, and that the action of Health Boards 
compelling the non-attendance at school of children living in domiciles where 
diphtheria is prevailing, is not only fully justified, but more stringent pre- 
cautionary measures are needed. R. T. Thorne, Lecturer on Public Health 
at St. Bartholomew's Hospital, stated in his third lecture on diphtheria, that 
at Pirbright each time the schools were closed diphtheria practically came to 
an end, and whenever they were reopened it recommenced suddenly and in a 
fatal form. This occurred without any obvious source of infection although 
much care was taken to detect it. 

Clinical observations in asylum and family practice justify the belief that 
1 American Lancet. (See Ann. Univ. Med. Sci., 1888.) 



368 CONSTITUTIONAL DISEASES. 

the following prescription, employed for purposes of disinfection, has been 
useful in the treatment of diphtheria as well as of scarlet fever : 

R. Acidi carbolici, 

01. eucalypti, da. £i (31 grammes). 

Spts. terebinthinse, 3 y iij (240 grammes). 

Add two tablespoonfuls to one quart of water in a tin or zinc wash-basin or a pan 
with a broad surface, and maintain a constant state of ebullition or simmering 
in the room occupied by the patient. 

A vessel with a broad surface is required for the purpose of producing a large 
amount of vapor, and to prevent ignition of the turpentine, which has occurred 
in a few instances when my directions were not strictly followed. Observa- 
tion in regard to the use of this vapor thus far show that it is an efficient 
germicide, preventing to a considerable extent the propagation of the disease 
to others, and enabling the physician to visit subsequent patients without 
risk or much less risk of communicating diphtheria through his infected per- 
son or clothing. 

In a paper published by Charles Smith of Australia, the use of this vapor 
is strongly recommended, not only as a prophylactic but curative agent ; but 
he does not employ it in the manner recommended above. He prescribes 
what he designates a weak mixture : 1 ounce (31 grammes) of oil of euca- 
lyptus, 1 ounce (31 grammes) of carbolic acid, and 8 ounces (240 grammes) 
of turpentine ; or a stronger mixture containing the same amount of carbolic 
acid with six or four ounces of turpentine. A stronger mixture he believes 
would not be tolerated on account of its pungency. Smith's directions are 
the following : " In the mixture soak two cloths — linen or otherwise — about 
a foot square ; place one close to the face, the other on the pillow near the 
head, on pieces of paper, to avoid unnecessary soiling of the bedclothes. In 
adults or children over eight or ten years of age, one or two other cloths of 
the same size may be soaked and hung about the cot, or cloths soaked with 
the liquid may be used in the room." 

In order to prevent as far as possible the spread of diphtheria, stringent 
measures should be taken to prevent propagation of the disease by walking 
cases, by children mildly affected who are allowed to attend school and ride 
in public conveyances. I have in a number of instances seen children with 
diphtheria sitting with other children in the clinics at Bellevue. Recently I 
saw in consultation a child with fatal diphtheria, which apparently was con- 
tracted in the street by embracing a playmate who had been allowed to go 
out for the first time after an attack of the disease. In another instance a 
child went with its parent to a Sunday mission-school in one of the tenement- 
house sections of New York. Four or five days subsequently it had diph- 
theria, which was communicated to other children of the family, and one of 
them died. The philanthropic endeavor to benefit the poor children of New 
York by conveying them to rural localities in midsummer has, it is said, 
resulted in the occurrence of diphtheria in farming sections where it was pre- 
viously unknown. I have now under treatment a family with diphtheria, 
and the child first attacked states that a schoolmate sitting near her in the 
school complained of sore throat a few days previously. Certainly the safety 
of the public requires that all children with sore throats should be excluded 
from the schools whenever diphtheria is prevalent, and it should be the duty 
of teachers, acting under the direction of health boards, to see that this is 
done. 

Hygienic Treatment. — The patient should be placed in an airy room, and 
his evacuations should be promptly disinfected by chlorine, carbolic acid, or 
other disinfectant, and removed from the room. Purity of the air in the 



.-5 



DIPHTHERIA. 369 

apartment is required ; but in the ventilation draughts of air through the 
room should be avoided, on account of the liability to diphtheritic croup, 
which produces about one-third of the deaths from diphtheria. M. Jules 
Simon recommends that the windows of the sick-room be constantly closed, 
and that ventilation be obtained through the open window of the adjoinin 
apartment. In bathing the patient care must be taken that he be not chilled 
Bathing should be performed expeditiously in a warm room, with perhaps 
some increase of the stimulants administered. The patient should be con- 
stantly in bed, and the temperature of the apartment should be from 70° to 
75° F. A uniform temperature of the apartment at about 73° F. is safest. 

All physicians of experience recognize the importance of the use of the 
most nutritious and easily-digested food and the preservation of the appe- 
tite, for diphtheria produces rapid destruction of the red corpuscles and loss 
of flesh and strength, and it may soon produce a state of dangerous weak- 
ness. Beef tea or the expressed juice of meat, milk with farinaceous food, 
etc., should be administered every two or three hours or to the full extent 
without overtaxing digestion. I have sometimes employed the pepsin prepa- 
rations before each feeding, with apparently good results, as in the following 
formula : 

R. Pepsini puri, in lamellis, £j '■> 

Acidi muriat., dilut., ,^ij ; 

Glycerini, Jj ; 

Aquae purse, ^iv. — Misce. 
Dose : One teaspoonful before each feeding. 

In cases of feeble digestion the predigested foods are often very useful, 
as the beef peptonoids of Reed and Carnrick, the sarco-peptones of the 
Rudisch Company, and peptonized milk. Failure of the appetite and refusal 
to take food are justly regarded as very unfavorable signs. Trousseau says : 
" Alimentation occupies the first place in the general treatment ; and I have 
observed that the severer the attack the more imperative is the necessity to 
sustain the patients with nourishing food. Loss of appetite — that is, disgust 
for every kind of food — is one of the most alarming prognostic signs. We 
must try to overcome the loathing of food by every possible means ; and to 
get nourishment taken I sometimes do not hesitate, in the case of children, 
to threaten punishment. When the patient retains his appetite for food, there 
is good hope of recovery." l Occasionally, when great dysphagia is present, 
whether from the severity of the pharyngitis or from palatal paralysis, it is 
necessary to resort to rectal alimentation. The rectum absorbs, but does not 
digest, and it is capable of absorbing peptonized food to such an extent that 
life may be sustained without stomach digestion and solely by rectal alimen- 
tation. For the purpose of rectal alimentation I have usually employed 
peptonized milk containing in solution peptonized beef, as the sarco-peptones 
of the Rudisch Company. If this is administered through a No. 12 to No. 
14 elastic catheter introduced far enough to reach the sigmoid flexure, and 
retained for half an hour by a compress pressed closely against the anus by 
the fingers, the result is, I think, better than when we depend, as Trousseau 
did, entirely on stomach digestion. One objection to the use of the brush, 
instead of spraying the fauces with the atomizer, is that it is more likely to 
cause vomiting, by which nutriment, that is so much required, is lost. In 
malignant cases of diphtheria, as in scarlet fever of a similar type, patients 
are sometimes allowed to slumber too long without nutriment. It is the 
slumber of toxaemia, and should be interrupted at stated times in order to 
give food and stimulants. 

1 American Lancet. 
24 



370 COXSTITUTIOXAL DISEASES. 

Stimulants. — M. Sanne, in his treatise on diphtheria, says : " De tous les 
antiseptiques donnes a linterieur. l'alcool est de beaucoup le plus sfir. Plus 
l'infection est prononcee, plus il faut insister sur les composes alcooliques." 
He states that Bricheteau reports the history of a patient who took daily 
during diphtheria a bottle and a half of the wine of Bordeaux, without the 
least symptom of intoxication or headache. A similar case was related to 
me in which nearly one and a half pints of brandy were given in twenty-four 
hours without any ill effect, and with an apparent good result on the general 
course of the disease. The same rule holds true in diphtheria as in other 
acute infectious maladies, that while mild cases do ^ell without alcoholic 
stimulants, they are required in cases of a severe type, and should be admin- 
istered in large and frequent doses whenever pallor and loss of appetite or 
strength and flesh indicate danger from the diphtheritic or septic infection. 
It matters little how the stimulant is administered, whether milk punch or 
wine whey, provided that the proper quantity is employed. If given early 
and frequently in grave cases — as, for example, one teaspoonful every half 
hour of brandy or Bourbon whiskey — it does seem to have a tendency to 
render the disease more tractable ; but to be instrumental in saving life in 
malignant cases it must be given boldly from the start. If there be marked 
diphtheritic toxaemia when its use is commenced it will not save life, but it 
may prolong it. Although the liberal employment of alcohol is apparently 
useful, it cannot be regarded as a specific. In the quarantine wards of the 
New York Foundling Asylum were four children between the ages of three 
and five years who had been sick a few days with severe diphtheria, and it 
was evident at a glance that they must soon perish with the ordinary 
mild sustaining remedies. Quinine, iron, the most nutritious food and a 
moderate amount of alcoholic stimulants were being given, and we deter- 
mined to increase the Bourbon whiskey to a teaspoonful every twenty or 
thirty minutes day and night. Nevertheless, whatever the result might 
have been with the earlier commencement of this treatment, the blood-poi- 
soning was now too profound, and one after the other died. That intoxica- 
tion is almost never produced in this disease by large and frequent doses of 
the alcoholic stimulant is probably in part due to its quick elimination from 
the system, but more to the nature of diphtheria. 

Quinia. — In fulfilling the indication of sustaining treatment the vege- 
table tonics have long been used, especially cinchona and its alkaloid principle, 
quinine. The compound tincture of cinchona and the fluid extract have been 
used and recommended by physicians of experience, but of vegetable agents 
quinine has been and is still more frequently prescribed than any other. But 
the doses employed vary greatly in size and frequency in the practice of dif- 
ferent physicians. It is administered for its antipyretic effect in large doses, 
so that twenty or thirty grains are given daily, and in small doses, as one or 
two grains every fourth hour, for its tonic effect. That there is nothing 
antagonistic in the action of quinine to the diphtheritic virus, and that it is 
beneficial in the same way as in the other acute infectious diseases, and no 
further, is, I think, generally admitted by physicians. Large and frequent 
doses do not. apparently, produce any controlling action on the course of the 
disease or diminish the blood-poisoning. Cases might be cited in illustration. 
In the case of a child of four years with malignant diphtheria forty-eight 
grains administered daily had no appreciable effect in staying the fatal prog- 
ress of the disease. 

Quinine in doses of three to five grains has been prescribed as an anti- 
pyretic in diphtheria, as also in the other infectious diseases ; but as an anti- 
pyretic it is not very efficient, and the temperature after the first two or three 
days in diphtheria is not often so elevated that an antipyretic is required. 



DIPHTHERIA. 371 

As a tonic in doses of one to two grains it is probably to a certain extent 
beneficial, and it has been highly recommended by good observers for its local 
action upon the fauces when used by insufflation. The late Prof. Rochester 
of Buffalo recommended and practised in the treatment of diphtheria the 
insufflation of sulphate of quinine, in powders of two grains, upon the faucial 
surface, every two hours. 1 It is not improbable that benefit may result from 
its local action, for used in this manner it is antiseptic. But the employment 
of this agent by insufflation is very unpleasant to the child, and is likely to 
be resisted. Given in solution in doses of two grains, as in the following 
formula, it produces some local action on the fauces if drinks be withheld 
subsequently for a few minutes, and at the same time some tonic effect prob- 
ably results from its use in this manner : 

R. Quiniae sulphat, £ss ; 

Syr. yerbse santse comp., Jjij. — Misce. 

Give one teaspoonful every two to four hours to a child of five years. 

I have often prescribed quinine in this manner with apparent benefit in the 
treatment of diphtheria. 

Tinctura Ferri CMoridi. — All physicians who are familiar with diphtheria 
have noticed the pallor and loss of appetite, flesh, and strength which com- 
mence before the close of the first week in severe cases, and which are always 
unfavorable symptoms, indicating as they do rapid and progressive deteriora- 
tion of the blood. The use of iron is at once suggested as the proper medic- 
inal agent to arrest this blood-change, from its known effect in increasing the 
number of red blood-corpuscles and the amount of coloring matter in these 
corpuscles. By its effect on the red corpuscles, which are the carriers of 
oxygen, it increases the functional activity of organs and improves the gen- 
eral nutrition. The ferruginous preparations, therefore, hold an important 
place in the therapeutics of diphtheria. The one which has stood the test of 
experience and is now commonly employed is the tincture of the chloride of 
iron. It should be given in large and frequent doses, and five drops hourly 
to a child of three years. 

Ferguson 2 regards the tincture of the chloride of iron as the most valu- 
able of all remedies for diphtheria. He examined the blood daily or every 
second clay in twenty cases of diphtheria, and was astonished to observe how 
rapidly the red blood-corpuscles were reduced in number, those remaining 
presenting an unhealthy appearance. He believes that the iron partially 
arrests the blood-change. He administers as much as can be tolerated. It 
can be given in the syrup of pineapple in the following formula : 

R. Tinct. ferri chloridi, ^iij ; 

Glycerini, ^ss ; 

Syr. ananassse sativa, ^iv. — Misce. 

M. Jules Simon says : 3 " For internal treatment from three to six drops of 
the tincture of the chloride of iron should be given in a little water every two 
or three hours ; but it should not be given with milk or gum-water or from a 
metallic spoon, on account of the decomposition which occurs, which may pro- 
duce digestive troubles." 

The tolerance of a drug depends largely on the manner in which it is used. 
The best vehicle for the tincture of the chloride of iron is glycerine and the 
syrup of pineapple (syrupus ananassse sativa), or it may be conveniently em- 
ployed with two or three times its quantity of glycerine and a certain number 

1 New York Medical Journal. 2 Canadian Practitioner. 3 Le Progh medical. 



372 CONSTITUTIONAL DISEASES. 

of drops administered in water. The advice of Simon should be borne in 
mind not to give iron in gum-water, in milk, nor from a metallic spoon. 

That now after half a century of the constant use of iron in diphtheria in 
both hemispheres, there is an almost unanimous verdict in its favor renders it 
probable that the few who have not observed its good effects have treated 
unusually bad cases, or have given the medicine in small and inadequate 
doses. 

There is another form of iron employed, from which I have obtained the 
best results. The following is the formula : 

R. Acidi carbolici, gr. x ; 

Liq. ferri subsulphatis, ^iij ; 

Glycerini, 3J. — Misce. 

To be applied with a large camel-hair pencil, from three to six hours ; diluted 
with two or three times its quantity of water. 

It is destructive in a high degree to microbes, and it congeals the niuco- 
pus, which comes away abundantly, to the great satisfaction of the friends, 
who suppose that the pseudo-membrane is being detached. This remedy is 
a powerful detergent, so that if its use precedes solvents the latter act much 
more effectually. The thorough use of the iron astringent leaves nothing 
adventitious to cover and protect the pseudo-membrane from the action of 
the solvent. 

Potassium Chlorate. — This agent produces a curative effect on buccal 
inflammations, and its beneficial action when employed for the various forms 
of stomatitis has led to its extensive use in pharyngitis. When taken inter- 
nally it is eliminated in part by the salivary glands, so that it continues to 
exert in part a local action on the surface of the mouth and fauces until it is 
entirely eliminated. This medicine, the potassium chlorate, has of late years 
become also a domestic remedy, but the laity should be cautioned in reference 
to its use. It is an irritant to the kidneys in large doses, producing intense 
inflammatory congestion of these organs and arresting their function. The 
melancholy fate of Dr. Fountaine of Davenport. Iowa, in 1861. whose life 
was sacrificed by an experimental dose of potassium chlorate, is remembered 
by the older physicians. Fountaine took half an ounce in a gobletful of 
warm water at eight a. m. Free diuresis occurred, which ceased at four 
p. m. Though fatigued and pallid, he ate a hearty supper. During the 
following night he was in collapse, with vomiting and purging and severe 
abdominal pain. Early in the following morning he voided two ounces of 
dark urine, after which no urinary secretions occurred. The choleraic symp- 
toms returned, with collapse, but he again rallied. He had vomiting and 
intense and constant abdominal pain during the subsequent six days, when 
death occurred. The total cessation of fecal and urinary evacuations for six 
days was a notable fact. At the autopsy the lesions of an intense and gen- 
eral gastro-intestinal inflammation were present, the mucous membrane hang- 
ing in shreds and patches ; the bladder was empty, and its mucous membrane 
presented a similar appearance to that of the stomach and intestines. The 
condition of the kidneys is not stated, except that there was liquid resembling 
urine under the capsule of one kidney and crystals of the chlorate were in 
the pelves of the kidneys. A few years since, in my practice, a child of three 
years with active diphtheritic pharyngitis was allowed to quench its thirst 
by drinking water from a small pitcher in which three drachms of potassium 
chlorate had been dissolved, and which had been ordered as a gargle. In 
the morning I was summoned in haste, and found the surface of the patient 
cold and blue and pulse feeble. The urine was totally suppressed, and instead 



DIPHTHERIA. 373 

of it a few drops of blood passed from the urethra. Death occurred before 
night . 

Jules Simon 1 says that potassium chlorate, acting wonderfully well in dis- 
eases of the mouth, produces no beneficial effect in diseases of the fauces, and 
it weakens the little patient when given in large doses. Dr. J. P. Esch says 
that he has observed that the potassium chlorate used internally in diphtheria 
almost invariably produces symptoms of nephritis. 

After such an extensive use of potassium chlorate during nearly half a 
century its therapeutic uses should be clearly defined, and any ill effects which 
may result fully determined. From what is now known of its action, it would 
be better to abandon its use in diphtheria, since it is a remedy of doubtful efli- 
cacy for throat affections. 

Hydrargyri CMoridum Corrosivum (Hydrargyvi percMoridum, Br. Phar.). — ■ 
The use of this agent in the treatment of diphtheria is based on the theory 
of the microbic origin of this disease. Corrosive sublimate is the most active 
and certain of the germicide agents employed in medicine, whether used 
locally or internally. It quickly destroys all micro-organisms with which it 
comes in contact, and in safe medicinal doses it is believed to penetrate all 
parts of the system. The employment of corrosive sublimate in the treat- 
ment of diphtheria is not new, since it appears that the late Dr. Tappan of 
Steubenville, Ohio, prescribed it with apparent benefit in 1860-61 ; but it 
was seldom prescribed as a remedy in this disease until within the last four or 
five years. The establishment of the theory of the microbic origin of diph- 
theria, and a knowledge of the fact that the sublimate is the most efficient 
germicide, have made it the favorite remedy with many physicians. Of 
course its employment demands caution, and is justified only by the fact that 
the disease for which it is prescribed has hitherto been very fatal with other 
modes of treatment. Though this agent is now widely used for diphtheria, 
medical journals thus far contain very few reports of its supposed toxic or 
injurious action, while many physicians believe that it diminishes the virulence 
of diphtheria and increases the percentage of recoveries. 

In ordinary cases the following may perhaps be regarded as about the 
proper quantities which should be administered in divided doses in twenty- 
four hours : For a child of two years, gr. -i- (gr. fa every two hours) ; for a 
child of four years, gr. \ (gr. fa every two hours) ; for a child of six years, 
gr. 1 (gr. fa every two hours) ; and for a child of ten years, gr. J (gr. fa 
every two hours). Thus, if we employ the vehicle which Dr. Tappan used 
a quarter of a century ago, the following prescription might be written for a 
child of six years : 

R. Hyd. chlor. corros., gr. j ; 

Alcoholi, 3y ; 

Elix. bismuthi et pepsinii, q. s. ad ^iv. — Misce. 
Dose : One teaspoonful every two hours. 

Dr. Oatman of Nyack, New York, has lost but 1 patient in 23 by the 
following local treatment : Cotton is firmly wound around the end of a 
stick about the size of a lead-pencil, being drawn out as it is wound, and 
made to project beyond the end. This is dipped into a solution of the bichlo- 
ride of mercury, two grains to the pint (1 to 3840), and passed into the throat 
until it touches the posterior wall of the pharynx. It is then instantly with- 
drawn and burnt. This treatment is repeated hourly with a new swab each 
time, until the inflammation begins to subside, which is usually in forty- 
eight hours. 

1 Le Proges medical. 



374 CONSTITUTIONAL DISEASES. 

Two of the prominent physicians of New York have informed me that 
they have witnessed poisonous effects from the corrosive sublimate in diph- 
theria, and I can add to the list fatal poisoning from its local use in another 
disease. Hence its cautious local application in some such manner as that 
recommended by Oatman seems preferable in the majority of instances. 

Calomel. — Physicians of ample experience have recommended calomel in 
the treatment of diphtheria, some in laxative doses and only at the beginning 
of the attack, and others in doses of the fractional part of a grain every two 
to four hours during the sickness. The majority of physicians — very prop- 
erly, in my opinion — discourage the employment of calomel in laxative doses, 
believing that it tends to weaken the patient and increase the anaemia, which 
in all cases of severe diphtheria soon becomes very manifest, whatever the 
treatment ; but a single laxative dose is perhaps sometimes useful. It may 
do good, as in other infectious diseases, to unload the primse, vise, in the com- 
mencement of the attack, so that the remedies to be employed are more readily 
absorbed and without alteration by admixture with chemical products in the 
intestinal tract. What change calomel undergoes so that it can be absorbed 
has not been clearly ascertained. 

Trypsin and Papoid. — Trypsin, unlike pepsin, is an active solvent in an alka- 
line medium, and it maybe effectually employed in combination with alkaline 
mixtures. Dr. F. C. Fernald relates the case of a boy of six and a half years 
who had perforations of each membrana tympani and commencing pseudo- 
membranes upon the tonsilar portions of the fauces and the right auditory 
canal was covered with a diphtheritic exudate, entirely occluding it, so that 
liquids did not flow from the external ear to the fauces as formerly. The ear 
was filled every half hour with the following mixture : 

R. Trypsin, gr. xxx ; 

Sodii bicarbonat., gr. x ; 

Aquse destillat, ^ss. — Misce. 

The fibrinous exudate gradually dissolved and disappeared, the passage 
through the ear and Eustachian tube became open, and the patient recovered. 
The literature of trypsin contains other equally striking cases, showing the 
solvent power of this agent. 

Papoid, also designated papayotin and vegetable pepsin, is a digestive fer- 
ment obtained from the fruit of the South American melon tree. Its diges- 
tive power has been fully investigated by H. H. Chittenden of the Sheffield 
Scientific. He stated that it " has the power of digesting all forms of pro- 
teid or albuminous matter" in neutral acid or alkaline media. In his opinion 
the commercial papoid is " a mixture of vegetable globulin albumoses and 
peptone, with which is associated the ferment." He details his experiments 
on the raw blood fibrin which comes nearest chemically to the so-called pseudo- 
membranes, such as are found in diphtheria. 

The following facts ascertained by Prof. Chittenden are important in refer- 
ence to the use of this agent in pseudo-membranous inflammations whatever 
their location. Its proteolytic action is increased by the presence of an alka- 
line medium, in some cases greatly increased by the presence of 2 to 4 per 
cent, of sodium bicarbonate ; the highest digestive power is obtained in the 
presence of sodium bicarbonate. We cannot affirm that any alkaline reacting 
fluid will give the same increase in digestive action as sodium bicarbonate. 
We will recommend presently a successful method of using trypsin and 
papoid. 

Peroxide of Hydrogen, Hydrogen Dioxide H 2 2 .— Sir B. W. Richardson 
states that in 1857, when he began experiments with the peroxide of hydro- 



DIPHTHERIA. 375 

gen. it was a rare chemical curiosity, never previously used in medicine, and 
he had therefore no guide from former experience. He first employed it in 
the strength of four and five volumes, and gradually increased the volumes 
to twenty and thirty. He soon learned that the action of oxygen from the 
higher volumes, released in the presence of pus and other substances, was so 
great and rapid that the effect was practically explosive, and after many trials 
he came to the conclusion that the ten-volume strength was the best for ordi- 
nary use. 

As frequently happens when an active and efficient remedial agent is first 
prescribed, its efficiency and full value were not appreciated. The peroxide 
was indeed seldom employed until it was brought prominently and favorably 
to the notice of the profession by E. R. Squibb, in 1889, who wrote : " It is 
perhaps the most powerful of all disinfectants and antiseptics, acting both 
chemically and mechanically upon all secretions and excretions so as to 
change their character and reactions instantly." 

The new medicine began to be used in surgical and in those medical cases 
which required local treatment, and the laudatory opinion of Squibb was in 
many instances justified by the result. But the pharmaceutical peroxide 
was soon found to be too irritating for use in the various inflammations of the 
fauces and nares in children, so that even a 15 volume solution diluted with 
two or more times its bulk of water, applied by spray or otherwise, increased the 
inflammatory hyperemia of the nasal, buccal, and faucial surfaces, sometimes 
causing in addition to the increase of inflammation, a pellicular exudation of 
fibrin, as when strong ammonia having a caustic action is used. Distinguished 
physicians, whose opinions influence practice in both hemispheres, related cases 
showing the pernicious effects of the peroxide applied by spray or otherwise 
to the nasal or faucial surface of the child in catarrhal or pseudo-membranous 
inflammation, so as to increase the area and severity of the inflammation and 
sometimes form a thin fibrinous exudate to which I have alluded. I might 
mention similar results in my own practice and that of others, the induced 
catarrhal and pellicular inflammation abating when the use of the peroxide 
was discontinued. The irritating action appears to be due to the sulphuric and 
phosphoric acids used in the manufacture of the peroxide. " It is necessary 
that solutions of hydrogen dioxide should be slightly acid when they are to 
be kept for even a few hours. If neutral or alkaline they will decompose at 
the rate of two or three volumes a day, and the faster the warmer the weather, 
and the stronger solutions would soon burst any ordinary bottles. Squibb 
states that the neutralization of the peroxide by such alkaline agent as the 
sodium bicarbonate does not diminish its efficiency, " provided this be done 
very near the time of using ; then by ordering the peroxide a little stronger 
than you want, to compensate the loss by decomposition, you could get a 
fairly uniform solution for say six or eight hours after sodium has been 
added, provided the bottle be kept in a cool dark place." 

The irritating action of the peroxide due to its hyperacidity may there- 
fore be prevented by adding to it an alkali as the sodium bicarbonate imme- 
diately before its use, so as to render it neutral or preferably alkaline when 
used. By so doing its germicide and antiseptic powers do not appear to be 
diminished. 

There can be no doubt that the peroxide of hydrogen is not surpassed as 
a detergent, and it should be used every hour or every half hour. If so used 
there is reason to believe that the nascent oxygen which it immediately sets 
free combines with the toxine generated by the bacillus and diminishes its 
poisonous properties. The prompt' chemical action of the nascent oxygen 
removes the muco-pus and causes it to flow from the nares or fauces in 
minute bubbles, and there is reason to believe that it changes to a certain 



376 CONSTITUTIONAL DISEASES. 

extent the character of the bacillus and toxine, if it be applied every hour 
or perhaps half hourly as a spray, rendering them less noxious. 

In order to complete the process of destroying the membrane, I obtain 
very successful results by utilizing the digestive action of trypsin and papoid 
according to the following formula : 

R. Trypsin, 
Papoid, 

Sodii bicarbonat., ad. j|ss ; 

Sulphur, sublimat., ^ij. 

To be insufflated every two hours immediately after the detergent action of 
the peroxide. The digestive power of the papoid has been investigated by 
R. H. Chittenden of the Sheffield Scientific School. He states " that it has 
the power of digesting all forms of proteid or albuminous matter in neutral 
acid or alkaline media." He details the soluble action of papoid on raw 
beef fibrin which resembled most closely the composition of the diphtheritic 
exudate. 

The remedies which we have mentioned are in my opinion the most effi- 
cacious and safest of those which pharmacy has heretofore furnished, but a 
new remedy, known as " antitoxin," has been so highly extolled by many 
eminent physicians as a remedy for diphtheria, that this new remedy demands 
attention if not employment wherever this fatal malady occurs. The distin- 
guished bacteriologist, M. Roux of Paris, gave a clear and full, but at the 
same time eulogistic description of the " antitoxic treatment " of diphtheria, 
at the meeting of the Congress at Budapest, as follows : Roux says that 
where the diphtheritic pseudo-membrane appears upon parts that are not 
visible the disease manifests itself by blood-poisoning, indicated by pallor, 
albuminuria, and respiratory and cardiac disturbances. If diphtheria be not 
early diagnosticated and be well advanced, antitoxin cannot be expected to be 
efficacious. He describes the method of preparing the serum as follows : The 
animal furnishing it, usually the horse or goat, is rendered immune against 
diphtheria — that is to say, it is rendered accustomed to the toxin of diph- 
theria. The preparation of antitoxin forms the basis of the treatment, and 
it is the more necessary to describe it because it requires a large quantity of 
the diphtheritic toxin to immunize large animals and to maintain their serum 
at a sufficient degree of activity. The most rapid method for obtaining the 
toxin employed for inoculating the animal consists in making a culture in a 
current of moist air. Vessels with flat bottoms and lateral tubes are used ; 
into these is poured an alkaline bouillon, peptonized to 2 per cent., the liquid 
being spread into a thin layer. " After sterilization, recent and very virulent 
diphtheria bacilli are added and the temperature of the chamber is raised to 
37° C. (98.6° F.). When the development has fully commenced, in a man- 
ner easily imagined, the current of air that passes into the neck of each of 
the phials is regulated after passing through a wash-bottle. After three 

weeks or, at most, a month, the culture is sufficiently strong to use 

Since 1892 we have immunized several horses, producing very efficacious 
serum. Some have been brought to such a degree of immunity in less than 
three months that they have borne, without suffering, 300 cubic centimetres 
(9J fluidounces) of diphtheritic toxin injected into the veins at one time. 
The immunization of horses is therefore very simple. The pure toxin is 
injected under the skin, commencing with 1 cubic centimetre (15* minims) 
and progressively increasing the quantity. At the end of a month, two or 
three times a week from 20 to 30 centimetres (5 to 8 fluidrachms) are injected 

at each sitting Horses also bear very well inoculations of living and 

very virulent diphtheritic bacilli These inoculations, after being 



DIPHTHERIA. 377 

repeated a great number of times, always give rise to the same symptoms, 
until a period is readied at which the fever following the inoculations is 
insignificant, and the much-reduced local lesion terminates in suppuration. 
Then large doses of virulent culture introduced into the veins only provoke 
a fleeting rise of temperature/' After the serum of the animal is rendered 
immune by repeated injections, extending over three months to two years, it 
is ready for the treatment of patients. 

Roux states that before treating children with the serum it is tested upon 
animals. The serum not only prevents general poisoning, but its action on 
the local lesion is most marked. That form of diphtheritic disease in chil- 
dren which is dreaded above all others by the laity as well as physicians — to 
wit, pseudo-membranous laryngo-tracheitis — experiments have shown to be 
more amenable to treatment by the antitoxic serum than by any or all other 
medicines. Roux says : " Rabbits to which tracheal diphtheria has been 
communicated (by injection of the diphtheritic material) die in from three 
to five days if not treated. Those receiving serum in sufficient quantity, 
even twelve or twenty-four hours after the injection, recover. Diphtheria 
associated with streptococci is the gravest form met with ; in children it is 
the most frequent determining factor of broncho-pneumonia, and the same 
holds good among rabbits." He believes that treatment begun in the first 
twelve hours, by repeated large injections of the serum, may arrest these 
cases of mixed infection in which both pathogenic germs — the Loeffler bacil- 
lus and streptococcus — are present and broncho-pneumonia is likely to super- 
vene. But your rabbits, treated after twelve hours, have succumbed in the 
great majority of cases, with centres of broncho-pneumonia, in which were 
found microscopically the Klebs-Loeffler bacillus associated with the strep- 
tococcus. 

Roux gives the statistics of treatment with antitoxin at the Hopital des 
Enfants Malades, Paris. From February 1 to July 24, 1894, 448 children 
were thus treated, the mortality being 109, or 24.33 per cent. The average 
mortality from 1890 to 1894 was 51.71 per cent, in a total of 3971 children. 
The benefit from the antitoxin treatment, the conditions being the same, was 
therefore 27.38 per cent. Within the same period 500 cases of diphtheria 
were entered at the Hopital Trousseau, 316, or 63.20 per cent, of whom 
died. Of the 448 children treated by antitoxin, 128 were found, by bacte- 
riological examination, not to be suffering from true diphtheria ; 20 other 
cases were in a dying condition when brought in. Of the 300 cases remain- 
ing there were 78 deaths, or 26 per cent., instead of 50 per cent., as in former 
statistics, before the use of antitoxin. The serum used was taken from 
immunized horses, with a strength of between 50,000 and 100,000. Of this 
20 cubic centimetres (5 drachms) were injected under the skin of the thigh. 
This was not renewed if the patient was found not to be suffering from true 
diphtheria; otherwise, a second injection was made twenty-four hours later. 
0.10 to 0.20 gramme (1J to 3 minims) being used. This was usually suffi- 
cient to bring about recovery. If the temperature remained elevated, how- 
ever, a third injection of the same amount was made. The average weight 
of the children being 14 kilogrammes (28 pounds), the amount of serum 
injected, as a general rule, equaled T wo" P ar *- °f their body-weight, and in 
exceptional cases y-J-g- part. Under the influence of the injections the gen- 
eral condition remained excellent ; the false membranes ceased to form 
within twenty-four hours after the first treatment ; in thirty-six or at most 
seventy-two hours they became detached. In only 7 of the cases did they 
persist longer. The temperature frequently fell suddenly after the first in- 
jection ; if it remained elevated in the cases of severe angina, it fell only 
after the second or third injection in lysis. The pulse returned to normal 



378 CONSTITUTIONAL DISEASES. 

less rapidly than the temperature. A third of the cases of diphtheria, ac- 
cording to statistics, show albuminuria ; and this having been present in only 
54 out of the 120 cases treated with serum, it seemed evident to Roux that 
the remedy diminished the frequency of the symptom. The mortality in 
cases of croup treated with the serum was also much less than with other 
methods. 

In mixed infection, in which the streptococcus and Loeffler bacillus are 
associated, the antitoxic serum is less efficacious than in those cases in which 
the streptococcus is absent. Roux states, as the result of his observations^ 
that when the diphtheritic inflammation extends to the larynx and tracheotomy 
is necessary the injections should be more abundant and more numerous. 
In the majority of cases thus treated the diphtheritic exudate disappears 
more rapidly from the larynx and trachea, and the cannula can ordinarily be 
withdrawn on the third or fourth day. 

Tubage being an American invention, the American reader will be 
pleased when he reads the following sentences with which Roux terminates 
his highly-instructive paper : " How many children may be spared trache- 
otomy if the serum were administered sooner ? We can even say that, with 
the use of serum, tracheotomy should, in the great majority of cases, be 
replaced by intubation. It is now no longer a question of leaving the tube 
in the larynx for days. It will suffice more frequently to retain it for 
twenty-four or forty-eight hours, to prevent imminent asphyxia and to give 
time for the false membranes to become detached. Intubation is the com- 
plement of the serum treatment of the future. Tracheotomy will be the 
exception, and greatly to the benefit of the children." 

A. I. H. Saw, 1 of London, relates six cases of diphtheritic croup treated 
by tracheotomy and Aronson's antitoxin. All except an infant of eleven 
months, moribund on admission, recovered rapidly. At a meeting of the 
Brighton Medico-Chirurgical Society held October 4th Richardson and Hollis 
each related two cases in which the antitoxin was employed, with speedy 
recovery in all. One of Hollis's cases was cyanotic from croup and was 
tracheotomized before the antitoxin was injected. 

I. A. Turner 2 has collected the following statistics of the antitoxin treat- 
ment : Behring and Kossel, 30 cases, with a mortality of 20 per cent. ; Ehr- 
lich, Kossel, and Wasserman, 67 cases with tracheotomy, with a mortality of 
23.6 per cent. ; Kartz, 123 cases, with a mortality of 13.2 per cent. ; Weilger, 
63 cases, with a mortality of 28 per cent ; Aronson, 192 cases, with a mor- 
tality of 13 per cent. ; Roux, 448 cases, with a mortality of 24.3 per cent. 
This gives a total of 1081 cases, with a mortality of 24 per cent. 

At a recent meeting of the Royal Society of Physicians of Vienna, 
Widehofer 3 reported the results obtained in 100 severe cases of diphtheria 
treated during October and November with antitoxin. Of this number 74 
recovered, 24 died, and 2 were yet under observation. Diphtheria bacilli 
were found in all the cases except 4, 2 of which were not examined bacterio- 
logically. In the preceding nine months the mortality had been 52.6 per cent. 

Prof. Augustus Caille of the New York Polyclinic stated, in a paper read 
May 27, 1895, before the American Pediatric Society, " being fortunate in ob- 
taining from abroad an early supply of the antitoxin, I have been able thus far 
to observe its action in 41 cases of Klebs-Loeffler diphtheria, of which 7 
cases have had a fatal termination. Of the 34 cases ending in complete 
recovery, 32 were treated with Behring's or Aronson's serum, 2 with serum 
from the Gibier Institute, New York. In the majority of cases one injec- 
tion (600 units) was given ; in one-third of the cases, two and three injections 
were administered. Judicious stimulation was carried out in all cases, and 
1 October 13, 1894. 2 November 24, 1894. 3 No. 52, 1894. 



DIPHTHERIA. 379 

nasopharyngeal irrigation was practised in all cases, with salt water or mer- 
curic bichloride 1 : 5000. Our clinical experience has so far upheld the claim 
made for the antitoxin of diphtheria as to its specific and curative powers, for 
a reduction of the mortality from diphtheria is conceded by the vast majority 
of unbiased and competent observers." 

We cannot write so favorably of the use of antitoxic serum in the New 
York Foundling Asylum. Since a reliable preparation was obtained from 
the Health Board 31 cases were inoculated with the serum. The number of 
units employed varied from 500 to 2200. The antitoxin was inserted under 
the skin on the first day in 12 cases, on the second or third day in 17 cases, 
and on the fourth or fifth day in 2 cases. Nineteen received the injection 
once, nine received it twice, and three three times. Microscopic examinations 
revealed the presence of the Loeffler bacillus in all the cases, and the strep- 
tococcus in nearly all the cases, so that in all. or nearly all, the infection 
was a mixed one. The physicians who observed these cases and wit- 
nessed the necropsies and microscopic investigations could not resist the 
conviction that the broncho-pneumonia of which so many died was due to 
the streptococcus, which was abundant in the lobules, and upon which microbe 
the antitoxin has little or no eifect. Results: Recovered, 14; died, 17 (14 
from broncho-pneumonia or broncho-pneumonia and croup). In four or five 
of the cases the benefit was very marked after the use of the antitoxin. 

It is seen that statistics thus far are favorable for the antitoxine treat- 
ment, but it must be recollected that the type of the microbe diseases fre- 
quently changes, so that the experience of several years is often necessary in 
order to determine the full value of a remedy. 

Albuminuria. — This being due to septic nephritis, patients have seemed 
to be more benefited by the tincture of the chloride of iron, in frequent and 
rather large doses, than by any other remedy. If while this is being used a 
marked diminution in the quantity of urine occurs, it may be necessary to 
employ diuretics and laxatives, as in scarlatinous nephritis. The potassium 
bitartrate or acetate, and perhaps the more laxative salines, may be needed 
under such circumstances. But marked diminution of urine — and especially 
anuria — in diphtheria ends fatally, with few exceptions, according to my 
observations, whatever the treatment. 

Paralysis. — The loss of the tendon reflexes, and palatal and multiple 
paralysis, require the same stimulating and sustaining remedies which are 
appropriate for the primary disease, diphtheria. Iron and other tonics, nutri- 
tious and easily-digested diet, massage, and in some instances electricity, 
suffice to restore the use of the affected muscles, but sometimes weeks and 
even months elapse before their use is fully restored. So long as the paral- 
ysis does not affect any vital organ, a favorable prognosis may be expressed, 
although recovery may be slow. 

On the other hand, it is evident from its nature and from the cases 
which have been related that cardiac paralysis is exceedingly dangerous. 
and must be treated promptly and by the most active remedies. As we 
have seen, the attack of cardiac paralysis is usually sudden, with little fore- 
warning, and is often fatal before the physician, promptly summoned, is able 
to arrive. The patient should be as quiet as possible in bed, with the head 
low, and alcoholic stimulants should be administered at once. In the sudden 
seizures, such as have been related above, hypodermic injections of brandy 
act most promptly in sustaining the heart-action. Ammonia, camphor, musk 
and the electrical current may be useful auxiliaries. The predigested beef 
preparations, peptonized milk and other concentrated foods, designed for those 
with feeble digestion, are useful. If the urgent symptoms are relieved by these 
measures such remedies should be employed as are useful in other forms oi 



380 CONSTITUTIONAL DISEASES. 

diphtheritic paralysis. The patient is ordinarily feeble, anaemic, and with 
poor digestion. The beef extracts and concentrated foods should be con- 
tinued. Iron, quinine in moderate doses, and alcoholic stimulants are indi- 
cated. The use of the electric current is suggested by the nature of the 
attack. Many physicians believe that they have obtained benefit from its 
use in the treatment of the more common forms of diphtheritic paralysis, 
while others speak doubtfully of its efficacy. If there be reason from the 
symptoms to suspect the presence of central lesions in the nervous system, 
the galvanic current in short sittings has been recommended, and not the 
faradic. In ordinary cases either the direct or the induced current may be 
employed. 

Strychnine is, however, regarded by good observers as the most efficacious 
nerve-stimulant in the various forms of diphtheritic paralysis. Oertel's 
objection, expressed twenty years ago, to the use of strychnine in this disease, 
that, acting as an excitant of the spinal cord, it is likely to aggravate central 
lesions, was founded on a wrong understanding of the pathology of the 
paralysis. Prof. Henoch cured diphtheritic paralysis in three weeks by 
hypodermic injections of strychnine. W. Reinard ] states that a boy three 
and a half years of age fifteen days after the appearance of the diphtheritic 
patches on the tonsils had paralysis of the inferior extremities and the velum 
palati, a tottering gait, nasal voice, and difficult deglutition. At the end of 
twelve days death seemed imminent, the paresis of the lower extremities had 
become a complete paraplegia, and the paralysis of the upper extremities and 
of the muscles of the nucha, larynx, and thorax was complete. He was 
unable to sustain himself in the sitting posture, his head falling heavily on 
his chest. He had also dyspnoea, hoarse cough, tracheal rales, and aphonia, 
probably from cardio-pulmonary paralysis. Reinard made a hypodermic 
injection each day of one milligramme (about one-sixty -fifth of a grain) of 
sulphate of strychnine in the nucha. Improvement occurred in twenty -four 
hours in the tonicity of the muscles. On the third day the cardiac and pul- 
monary paralysis had so improved that the tracheal rales had ceased. The 
respiration was more normal and deglutition possible. On the fifteenth day 
of this treatment and after fifteen injections the patient was considered 
cured. Dr. Gerasimow 2 relates the case of a child six years of age who had 
paralysis of the velum, pharynx, larynx, and lower extremities. Six weeks 
after the commencement of paralytic symptoms subcutaneous injections of 
strychnine (or about one-thirty-first of a grain), were given daily. With 
this treatment the patient improved, and after seven injections of this 
strength, followed by twelve of one-twenty-second of a grain, the cure was 
complete. 

With such strong testimony in favor of the use of strychnine, it is per- 
haps remarkable that physicians of experience state that they have not 
observed any marked benefit from its use in the treatment of diphtheritic 
paralysis. At a meeting of the New York Clinical Society, held December 
23, 1887, 3 Dr. Holt stated that he was yet to be convinced that strychnine 
possessed any specific value in this disease, though it was of much value as 
a general tonic. At the same meeting Dr. A. A. Smith stated his belief that 
tonics and time did more for diphtheritic paralysis than anything else. He 
had used electricity and strychnine, and had never been able to satisfy him- 
self that electricity did any good, and the effects of strychnine seemed to be 
not specific, but those of a general tonic. On the other hand, Dr. Thatcher 
of New York has reported a case in which galvanism was employed on the 
two paralyzed upper extremities alternately, on each for a week at a time. 

1 Deutsche med. Wochenschr., 1885, No. 19. 2 Med. Obser., No. 20. 

3 New York Medical Journal, Jan. 14, 1888. 



PERTUSSIS. 381 

It was invariably found that the arm receiving the electricity gained more 
rapidly than the one untreated, the strength being tested by the dynamom- 
eter. This test seems to have been conclusive as showing the efficacy of 
galvanization. 



CHAPTER VIII. 
PERTUSSIS. 

Pertussis is a highly contagious disease attended and manifested by a 
catarrh of the air-passages. This catarrh gives rise to a cough which does 
not differ, during the inception and in the declining period, from that in an 
ordinary catarrh, but during the middle period of the malady is spasmodic. 
Exceptionally, the system is so mildly affected that the spasmodic element 
of the cough is lacking through the whole course of the malady or is con- 
fined to a brief period. The spasmodic cough has been attributed to the 
irritating and disturbing action of the specific principle on the nerves 
which control the muscles of respiration. It is attributed to the impres- 
sion produced upon the filaments of the pneumogastric, especially upon 
those of the internal branch of the superior laryngeal nerve, by the mucus 
which collects in the larynx and trachea, and which is known to contain 
the contagious principle in abundance. This cough consists in a series of 
forcible and loud expirations, followed by a noisy and difficult inspiration. 
Its special character is due to spasmodic contraction of the muscles of 
expiration, and notably of the small muscles of the larynx, so as to pro- 
duce narrowing or even closure of the aperture of the glottis. Each paroxysm 
of the cough usually ends (not always) in the expectoration of viscid mucus. 
With rare exceptions pertussis affects the same individual but once. Rilliet 
and Barthez report a case of its second occurrence, and West another case. 
I have attended two adult patients, both women of intelligence, who stated 
that they had had previous attacks in early life. Pertussis usually prevails 
as an epidemic, but is occasionally sporadic, at which time its type is mild. 
It is highly contagious through the breath of the patient or from exhalations 
from his surface. Pertussis is probably a disease of antiquity, but there is 
no clear description of it prior to the sixteenth century. Some have thought 
that it was alluded to in the writings of Hippocrates, and the Arabian phy- 
sician Avicenna who lived in the tenth century, in describing the " violent 
cough of children," which is attended by the spitting of blood and lividity 
of the face, probably alluded to it (Rilliet and Barthez). Baillon in 1578 
described a cough which appeared in Paris, attacked chiefly children, and 
was so violent that it caused bleeding from the nose and mouth, and often 
vomiting. Wilson in 1682 and Schenck in 1695 also described a convulsive 
cough which we can apparently identify as pertussis. In the eighteenth 
century whooping cough was described by many observers in different parts 
of Europe, among whom we may mention Alberte (1728), Brendel (1747), 
De Basseville (1752), Forbes (1755), Cullen, Butter, and Danz. In the 
present century, whooping cough, being eminently contagious and of such 
a nature that the patients are allowed to mingle in society, is widely dissemi- 
nated, and epidemics of it are of frequent occurrence. 

Incubative Period. — It is not improbable that this varies in different 
cases. Some writers believe that it is usually from two to seven days. In 
one instance I was able to ascertain it accurately. Mrs. B , having a 



382 CONSTITUTIONAL DISEASES. 

cough for two weeks, which was afterward ascertained to be that of pertussis, 
came from Boston to a family in New York. She remained with this family 
from 2 p. M., January 2, 1879, till the evening, when she left the city. During 
her stay she held and kissed an infant that was previously well and had never 
been removed from the floor on which it was born. Pertussis was not at that 
time prevailing in New York. On the 6th, or four days after exposure, the 
infant began to cough, and this proved to be the beginning of a severe attack. 

Age. — Most cases of pertussis are between the ages of one year and eight 
years, but it occasionally occurs in adults and even old people who have not 
been attacked previously. It is rare under the age of three months, but 
through the kindness of Dr. Ewing of New York I was enabled to see a 
new-born infant with pertussis whose mother had had the disease during the 
two months preceding her confinement. This infant was fifteen minutes old, 
and during the washing had the first convulsive seizure, which appeared to 
consist chiefly of a spasm of the laryngeal muscles, with temporary suspen- 
sion of the respiration, and attended by deep lividity of the features, with 
some frothing from the mouth. These attacks occurred nearly every hour, 
with intervals of complete cessation of symptoms. The mucus between the 
lips finally became stained with blood, and death occurred on the third day. 
The mother, the intelligent wife of a clergyman, believes that the infant had 
similar attacks before its birth, for she frequently experienced in the last 
weeks of gestation what seemed to be strong convulsive movements in the 
foetus, the duration of which corresponded with that of the attacks in the 
infant. A similar case is related by Billiet and Barthez, 1 and another by 
Keating. 2 These cases throw light on the pathology of pertussis, for they 
show that the specific principle may enter the blood. 

Causes. — Climate, race, and nationality do not seem to exert any decided 
influence on the spread of pertussis. Females are somewhat more liable to 
be attacked than males, and. as we have seen, a large majority of the cases 
occur between the ages of one and ten years. Letzerich about the year 
1870 supposed that he had discovered the cause of pertussis in a microbe, 
which, received upon the surface of the air-passages in inspiration, increases 
rapidly and produces the spasmodic cough by its irritating action or the irri- 
tating properties which it imparts to the mucus. In the first stage of pertus- 
sis he found only the spores of the microbe, and at a more advanced stage, 
in addition to the spores, he discovered filaments. He placed mucus holding 
the cryptogram upon the fauces of the rabbit, and witnessed the production 
of pertussis in this animal. Recently, Burger 3 of Bonn states "that the 
micro-organism of pertussis is visible with a power of 340 to 600 diameters, 
appearing as little rods of unequal size. With a higher power it is seen that 
the rods have the biscuit form. The groups of bacteria are irregularly dis- 
seminated or disposed in line, and bear some resemblance to the leptothrix 
buccalis. The method of preparation is very simple. A small quantity of the 
expectoration is pressed between two cover-glasses, exposed to the flame of a 
Bunsen burner to coagulate the albumen ; the coloring matter is then added 
(watery solution of fuchsin or of methyl violet) ; it is then washed thoroughly 
in water, or the coloring matter removed by washing in alcohol, the bacteria 
alone remaining colored. These bacilli are not found in any other expectora- 
tion ; they are so abundant that it is difficult to contest their action ; their 
frequency is always in direct relation with the intensity of the disease." 
Dr. Poulet 4 also confirms the statement of a special micro-organism in per- 

1 Treatise on the Diseases of Children. 

2 System of Medicine by American Authors: Lea Bros., Philadelphia, 1885. 

3 Berlin, klin. Wochenschrift ; London Medical Record, May 15, 1884. 

4 La Scalpel ; London Medical Record, May 15, 1884. 






PEBTUSSIS. 383 

tussis from his examinations. In the St. Petersburgher med. Woch., 1887, a 
11 careful observer," Dr. Afanasieif, also states that he had discovered a bacil- 
lus in the sputum of pertussis which differs from all other bacilli. It occurs 
in the form of small rods, single, in pairs, or in chains. The length of the 
bacillus is 0.6 to 2.2 micromillimetres. Its cultures exhibit peculiar qualities. 
Inoculated in animals, it produces symptoms like those of human pertussis, 
and the air-passages of these animals exhibited the appearance of congestion 
and catarrh. In the St. Petersburgher med. Woch., in 1888, another distin- 
guished Russian observer, Seintschenko, writes that after many experiments 
he is able to make the following statements: 1. The bacillus of Prof. 
Afanasieff is specific ; 2. Bacilli may be found in the sputum about the 
fourth day of the disease, in some cases earlier ; 3. They multiply in the 
tissues of the body, and as they increase the severity of the disease increases ; 
4. The bacilli disappear before the entire cessation of the attacks of coughing, 
or when the paroxysms are reduced to two or four daily ; 5. With complica- 
tions — such as, for example, a catarrhal pneumonia — there is a great increase 
in the number of whooping-cough bacilli found in the sputum ; 6. A pneu- 
monia developing under these circumstances differs from ordinary attacks of 
catarrhal pneumonia ; 7. The bacillus of whooping cough is of value, not 
only in etiology and diagnosis, but in the prognosis of the disease. 

After the lapse of six or eight years since the above announcements of 
the discovery of the specific principle of pertussis, the belief has gained 
ground that Afanasieff has probably made the genuine discovery. 

Lesions have been discovered in certain fatal cases which have been sup- 
posed to throw light on the etiology of pertussis, but which are now known 
to have been merely coincidences or results of the disease. Such are con- 
gestion of the spinal cord and its meninges, hyperemia of the pneumogas- 
trics. and tumefaction of the tracheo-bronchial glands, which it was claimed 
produced the spasmodic cough by compressing the recurrent laryngeal nerve. 

Pathological Anatomy. — Catarrhal inflammation of the air-passages 
is uniformly present. It occasionally occurs on the mucous surfaces of the 
nostril and pharynx, but is often absent from these parts. In the majority 
of patients the inflammation affects the surface of the glottis and that below 
the glottis. Herff examined his own larynx during paroxysms of pertussis. 
He observed a moderate inflammatory hypersemia of the respiratory tract 
during the entire course of the disease. The inflammation extended from 
the posterior nares to the bifurcation of the trachea, but was most marked 
in the following locations : over the cartilages of Santorini, Wrisber, and the 
arytenoid, and the posterior wall of the larynx, between the vocal cords and 
the epiglottis, and on the under surface of the epiglottis. The vocal cords 
themselves were not affected. During the paroxysm a pellet of mucus was 
observed upon the posterior surface of the larynx on a level with the glottis, 
and when this was removed the cough ceased. Irritation of this part of the 
larynx uniformly excited a cough. Sometimes certain alveoli are found dis- 
tended by a thick muco-pus, producing an appearance like minute tubercles. 

A common lesion found in the lungs of those who have perished with this 
malady is emphysema, affecting chiefly the peripheral portions of the upper 
lobes. It is usually vesicular emphysema, occurring from over-distension of 
the air-cells, but in some instances the air has escaped into the connective 
tissue, causing interstitial emphysema. According to my recollection of fatal 
cases which have occurred from time to time in the institutions of Xew York, 
and in which I have made post-mortem examinations, the upper lobes were 
exsanguine and inflated to nearly the fullest extent possible within the thorax, 
while other portions of the lungs presented areas of pneumonic or more or less 
complete atelectatic solidification. Pneumonia, atelectasis, and small extrav- 



384 CONSTITUTIONAL DISEASES. 

asations of blood in the lungs are, indeed, common lesions. Hyperplasia of 
the bronchial glands is also common, and hyperplasia has also been occasion- 
ally observed of other lymphatic glands, as the mesenteric. An ulcer under 
the tongue which observers have frequently noticed is now attributed to the 
pressure of the tongue on the lower incisors during the cough. 

In fatal cases small extravasations of blood in or upon the brain are com- 
mon, as is also passive congestion of the sinuses, veins, and capillaries, men- 
ingeal and cerebral, attended with more or less transudation of serum within 
the ventricles of the brain and between the meninges. Large dark and soft 
clots, and occasionally some that are white or yellow, are common in the intra- 
cranial sinuses, especially if, as often happens, death have occurred in convul- 
sions which supervened upon the severe spasmodic cough. 

Symptoms. — Pertussis consists of three stages : first, that of catarrh of 
the air-passages ; secondly, the stage of spasmodic cough, or, for brevity, the 
spasmodic stage ; thirdly, the stage of decline. 

The first period is characterized by the symptoms of coryza and bron- 
chitis, which present nothing peculiar or different from ordinary catarrh of 
the same parts, unless occasionally the cough be more frequent and teasing. 
Trousseau has known it to be repeated forty or fifty times per minute. The 
eyes present a moderately suffused appearance, and there is sneezing, with 
defluxion from the nostrils, but less than in the commencement of measles. 
The cough, which begins as soon as the catarrh affects the larynx, is accom- 
panied by little or no expectoration. The pulse and respiration are moderately 
accelerated, and such other symptoms as commonly accompany catarrh of a 
mild grade are present — to wit, increased heat of surface, thirst, and impaired 
appetite. 

The duration of the first stage varies in different cases. In severe whoop- 
ing cough it may last only two or three days, and in mild cases be protracted 
to five or six weeks. It may be absent especially in very young infants. We 
have alluded above to the new-born infant, in whom there is no first stage, a 
glottic spasm occurring soon after birth. The first stage commonly ends in 
from eight to fifteen days. In fifty-five cases observed by Dr. West its aver- 
age duration was twelve days and seven-tenths of a day. It is stated above 
that the first stage in rare instances continues during the entire course of per- 
tussis ; at least no spasmodic cough occurs. In two such cases which I now 
recall to mind, both girls, the inflammatory symptoms abated somewhat after 
the first few days, and an occasional easy cough remained, like that of simple 
bronchitis, and it continued during a period corresponding with the ordinary 
duration of pertussis. The diagnosis would have been doubtful, except for 
the occurrence of pertussis, with its regular stages, in other children of the 
same families. 

Second Period. — This may commence quite abruptly, but ordinarily its 
beginning is gradual. While the cough commonly has the character present 
in the first stage, it is now and then observed to be more severe and spasmodic, 
especially at night and when the patient is in any way excited. The spasmodic 
element increases, so that in the course of a week all doubt as to the nature 
of the disease is removed. 

The severity of the cough in the second stage varies considerably in dif- 
ferent cases. It sometimes commences quite abruptly, with little warning,, 
but commonly there is premonition of it, and the child endeavors to repress 
it. He experiences a tickling sensation in the throat or median line of the 
chest, or a feeling of constriction. He leaves his playthings and rests his 
head on his mother's lap or takes hold of some firm object for support ; his 
face has a grave or even anxious appearance, while the pulse and respiration 
are somewhat accelerated. Immediately the cough begins. It consists in a 






PERTUSSIS. 385 

series of short and hurried expirations, which expel a large part of the air 
contained in the lungs, followed by a hurried inspiration, which is difficult 
and noisy on account of the spasmodic contraction of the laryngeal muscles 
and narrowing of the glottic aperture. The sound which accompanies the 
inspiration, and which is often absent, especially in infants, is designated the 
whoop. The forcible expirations and difficulty experienced in expelling the 
air from the lungs on account of the constriction of the glottis afford expla- 
nation of the emphysematous distention of the air-cells in the upper lobes 
which we have seen is so common in severe pertussis. 

There may be a single series of expirations terminating in the manner 
stated, but often there are several such series embraced in a paroxysm. The 
cough commonly ends in the expulsion of frothy mucus from the bronchial 
tubes, and sometimes in vomiting. During the cough there is temporary 
arrest of blood in the lungs, leading to congestion in the right cavities of the 
heart and throughout the systemic circulation ; therefore the face is flushed 
and swollen, and occasionally hemorrhage occurs under the conjunctiva or 
from one of the mucous surfaces. The most frequent hemorrhage is epis- 
taxis. When the cough ceases, the normal respiration is restored and the ful- 
ness of the vessels immediately abates ; but often puffiness of the features is 
observed, due to serous infiltration of the subcutaneous connective tissue, 
and continuing for days or weeks during the period when the cough is most 
severe. The paroxysms last from a quarter to a half or even a whole minute, 
and in that time, in cases of ordinary severity, there are often as many as fif- 
teen or twenty series of expirations. 

At the close of the paroxysm, if there be no complication, the symptoms 
soon abate ; the temperature, pulse, and respiration become normal, and there 
is no evidence of disease. The cough in the second stage is much more fre- 
quent in one case than another. At the height of this stage it is generally 
more severe if it occur at long intervals than when frequent. During the 
week in which pertussis is most severe there is, on the average, about one 
paroxysm of coughing in each hour. 

The cough increases in severity till the third week of the second stage, or 
the thirtieth to the thirty-fifth day of the disease, after which it remains sta- 
tionary for a certain time. It is apt to be more frequent in the night than 
day-time. Sometimes it occurs while the child is quiet ; it may even awaken 
him from sleep, but it is often also produced by mental excitement or by 
physical exertion. Anger or fright gives rise to it, and therefore the child is 
likely to cough when being examined by the physician or when his wishes are 
not complied with. The ordinary duration of the second stage is from thirty 
to sixty days, It may, however, be considerably longer or shorter than this. 
The third stage, which commences at the time when the spasmodic cough 
begins to abate, is short, not continuing longer than two or three weeks. A 
protracted stage of decline indicates some complication. While the sputum 
in the second stage is mucous and frothy, that in the third stage is more 
opaque and puriform. 

In the third as in the second stage, if there be no complication, the pulse 
and respiration in the intervals of the paroxysms are nearly or quite natural. 
Febrile excitement may. however, now and then occur from trifling causes, or. 
indeed, without any apparent cause. The digestion and the general health in 
uncomplicated pertussis remain unimpaired, with the exception of more or 
less emaciation, which is likely to occur in all but the mildest cases in conse- 
quence of the frequent vomiting. After complete recovery it is not unusual 
for the spasmodic cough to reappear at times for one or even two years. The 
cough of ordinary simple laryngitis or bronchitis assumes this character. 
Complications. — These, like the symptoms, are chiefly of a twofold 

25 



386 CONSTITUTIONAL DISEASES. 

character — to wit, inflammatory and neuropathic. From the nature of 
the cough in pertussis, it would naturally be supposed that the spasmodic 
affection which is now designated internal convulsions, and which is charac- 
terized by spasm of certain muscles of respiration, would be a frequent com- 
plication. It does sometimes occur in young children, but it is not common. 
Clonic convulsions affecting the external muscles are, on the other hand, not 
infrequent. They occur chiefly in the second stage, when the cough is most 
severe, and in infancy much more frequently than in childhood. They are 
likely to be general and severe, or, if not of this character at first, to become 
such. The convulsions commence in most instances in or directly after the 
paroxysm of coughing, but they sometimes occur in the interval when the 
child is quiet. 

Rilliet and Barthez remark: " Almost all infants succumb to this com- 
plication, ordinarily in the twenty-four hours which follow the first attack ; 
nevertheless, life may be prolonged during two or three days " (article 
Coqueluche). In my own practice this complication usually ended fatally 
before bromide of potassium and chloral were employed, but with the proper 
use of these agents it can often be arrested. In the month of June, 1867, I 
was attending a little girl two years and four months old who had reached 
the fifth week of pertussis when she was seized with general clonic convul- 
sions. The mother, who was requested to keep a record of the number of 
convulsions, stated that there were twenty in all occurring within forty-eight 
hours. They affected both sides, the shortest lasting only three or four 
minutes, the longest seventy-five minutes. The treatment in this case, 
which eventuated favorably, will be noticed hereafter. 

In those who die of convulsions occurring in whooping cough the most 
constant lesion is congestion of the cerebral veins and sinuses, often with 
transudation of serum. This congestion is due in part to the cough which 
precedes the convulsions and in part to the convulsions themselves. At the 
autopsies which I have made of two infants who died in hospital practice 
from whooping cough, accompanied by convulsions, all the cerebral sinuses 
were filled with clots, which were generally soft and dark ; but in the lateral 
sinuses clots were found which were light-colored. The light color of a clot, 
either in a vein or sinus, indicates its ante-mortem formation. 

The gravity of the convulsive attack can be ascertained by observing 
whether the patient readily recovers consciousness. Its speedy return to con- 
sciousness indicates that there is no serious congestion. On the other hand, 
great drowsiness remaining or a semi-comatose state indicates persistent con- 
gestion, and perhaps even the formation of clots in the sinuses of the brain. 
Death from convulsions is usually preceded by coma. Occasionally menin- 
geal apoplexy supervenes upon the congestion, and death is immediate. 

The most frequent inflammatory complications are bronchitis and pneu- 
monitis. Inflammation of the bronchial tubes of a mild grade, we have seen, 
is a common accompaniment of pertussis, but when it extends to the minuter 
tubes or becomes so severe as to cause acceleration of respiration, it is prop- 
erly a complication. Both bronchitis and pneumonitis, occurring as compli- 
cations, are developed, with few exceptions, in the second stage. Bronchitis 
is accompanied by accelerated respiration and pulse and increased tempera- 
ture. The danger is proportionate to the amount of dyspnoea. 

Pneumonitis is a less common complication than bronchitis, but it occurs 
more frequently in pertussis than in any other constitutional malady of early 
life, excepting measles. The congestion which results and remains in the lung 
when the cough is frequent and severe favors the development of pneumonia. 
The symptoms and physical signs which accompany this inflammation and 
serve for its diagnosis are the same as in the primary form of the disease, 



PERTUSSIS. 387 

and are described elsewhere. Bronchitis or pneumonia usually moderates 
the severity of the spasmodic cough, for when the inflammatory element in 
pertussis increases the spasmodic abates. On the abatement of the inflam- 
mation, however, the cough usually regains its former convulsive character. 
The fact may be stated in this connection that any complication or intercur- 
rent disease which is attended by decided febrile reaction ordinarily renders 
the cough for the time less spasmodic. 

The occurrence of bronchitis or pneumonia is shown by the elevated tem- 
perature, acceleration of pulse and respiration, short and frequent cough. 
These symptoms do not cease so long as the inflammation continues, whereas 
in uncomplicated pertussis the patient seems nearly or quite well between the 
coughs. In pneumonia the respiration is accompanied by the expiratory 
moan, and in both bronchitis and pneumonia there is more or less depression 
of the inframammary region during inspiration. These symptoms, in con- 
nection with the physical signs, render diagnosis in most instances easy. 
Although the general character of the cough is changed, a cough now and 
then occurs, even when the inflammation is pretty severe, sufficiently spas- 
modic to indicate the nature of the primary affection. Capillary bronchitis 
and pneumonia are always serious complications. 

Not only is more or less emphysema a common complication of severe 
pertussis, but bronchiectasis also occurs in certain cases, due to the same 
conditions. Emphysema is a common lesion in young and feeble infants, 
even when there is no history of any previous severe disease of the respira- 
tory organs. I have found it one of the most common lesions in infants of 
feeble constitutions who die in the hospitals and asylums of New York, but 
it is usually interstitial and confined to a small part of the upper lobes. It 
is not accompanied by that general distention of the alveoli and consequent 
enlargement of the lobes which occur in the emphysema of pertussis. Its 
chief cause in these feeble and wasted infants appears to be impaired nutri- 
tion and change in the molecular state of the pulmonary tissue. The same 
molecular change often occurs in severe and protracted pertussis, and there- 
fore serves as an additional and efficient cause of the emphysema. 

The following was a not unusual case of this disease as it occurs in the 
tenement-houses and asylums of New York. At the meeting of the New 
York Pathological Society, October 14, 1868, I exhibited emphysematous 
lungs removed from an infant who died at the age of nineteen months at 
the commencement of the fourth week of pertussis. Death occurred from 
thrombosis in the lateral sinuses of the cranium, resulting from the severe 
spasmodic cough, eclampsia, and feebleness of the circulation, as the infant 
was previously in a reduced state from chronic entero-colitis. At the au- 
topsy the superior lobes of both lungs were found exsanguine, doughy to 
the feel, and enlarged so as to rise above the level of the other lobes. The 
resiliency and elasticity of the lung-tissue in these lobes were evidently 
greatly impaired, and their air-cells in a state of over-distention. The 
other lobes were healthy, except that one of them was the seat of catarrhal 
pneumonia. In this case there had been no disease affecting the respira- 
tory apparatus previous to the pertussis, so that the incipient vesicular 
emphysema was referable to the severe cough and impaired nutrition of 
the lungs. 

Occasionally we meet cases of severe pertussis in which, while there is 
over-distention of the alveoli of the upper lobes, collapse occurs over a greater 
or less extent of the lower lobes. Collapse, like emphysema, may continue 
for weeks or months subsequently to pertussis, and then gradually disappear, 
but in the following case, rare in my experience, it was permanent : John 
O'Neil, aged five and a half years, was brought to the Bureau for the Relief 



388 



CONSTITUTIONAL DISEASES. 



of the Out-door Poor in New York in December, 1876. He lived in the 
underground basement of a tenement-house, and was supported by charity, 
except at intervals, when his father, who was dissipated, could obtain work. 
At the age of fifteen months he had a glandular swelling on the right side of 
the neck, which suppurated, and three months later one on the opposite side, 
which also suppurated. At the age of two and a half years he had bron- 
chitis, the cough of which did not abate till two months subsequently. 
When near the age of three years he had measles, and the cough from this 
disease lasted three or four months. In the summer of 1875, or about one 
year subsequently to the measles, he contracted pertussis, which was severe, 
but was allowed to run its course without treatment. It lasted four months, 
never, however, confining him to bed or materially impairing his appetite. 
One morning about the close of the second month of the malady the parents 
first observed depression of the right side of the thorax. This gradually 
increased a few weeks, and has been permanent. The parents stated that he 
had never been confined to the house or without appetite except during the 
week of measles. 

Since his recovery from pertussis he has had his usual appetite and gen- 
eral health, but crying or excitement commonly brings on a pretty severe 

cough. The depression of the thorax, examined 
in front, begins quite abruptly in the line of the 
left costo-chondral articulations. Circumferen- 
tial measurement of the left side from the mid- 
dle of the sternum to the spine, the tape lying a 
little below the nipple, gives eleven and a half 
inches, while corresponding measurement of the 
right side gives seven and a half inches ; pulse 
136, sounds of the heart normal ; respiration 44. 
On auscultation over the right side of the chest 
we observed bronchial respiration and a feeble 
bronchophony, with perhaps slight vocal fre- 
mitus. The accompanying figure is from a 
photograph by Mr. Mason, photographer to 
Bellevue Hospital. My first impression on ob- 
serving this case was that it was one of unex- 
panded lung which had been compressed by a 
pleuritic effusion, but it is seen that the history 
points clearly to pertussis as the cause of the 
deformity. The depression occurred somewhat 
suddenly when the cough was most severe and 
when there was no fever, loss of appetite, or 
other symptoms of pleuritis. The patient had 
not presented any marked evidence of rachitis, 
but was decidedly strumous. 

Pertussis is sometimes complicated by the 
eruptive fevers. There does indeed seem to be 
some affinity between it and measles, so that 
many epidemics of the two have been observed 
at about the same time. During my term of 
service in the New York Foundling Asylum, in May, 1878, measles and 
pertussis prevailed in the wards at the same time. Eighteen of the chil- 
dren who were having pertussis contracted measles, and the Sisters, who 
were very intelligent and faithful observers, and were requested by me to 
notice the effect of the complication, stated that with few exceptions the 
severity of the whooping cough was increased during the continuance of 




PERTUSSIS. 389 

the exanthem. This is contrary to the general belief of the eifects of inter- 
current febrile diseases. 

Diagnosis. — During the period of invasion it is impossible to diagnosticate 
pertussis. Its nature can only be conjectured from a known exposure or from 
the epidemic occurrence of the disease. In the second stage, which is cha- 
racterized by the spasmodic cough, diagnosis is ordinarily easy, and often the 
parents are able to announce the nature of the disease when the physician is 
called. Still, a mistake is sometimes made : a spasmodic cough very similar 
to that of pertussis occasionally occurs in other maladies. Young infants 
with bronchitis frequently experience great difficulty in the expectoration of 
mucus, which collects in the air-passages and provokes a suffocative cough. 
The following facts will aid in making the diagnosis : Bronchitis, accompanied 
by a suffocative cough, is an acute disease, and the cough occurs at an early 
period, usually in the first week. It lacks the inspiratory sound or the whoop, 
and is associated with constantly accelerated respiration and well-marked febrile 
symptoms, dependent on the inflammation. Moreover, the cough is occasion- 
ally suffocative, according to the amount of mucus in the tubes. The spas- 
modic cough of pertussis, on the other hand, is preceded by the stage of inva- 
sion, and it occurs only in the second stage, when the febrile symptoms have 
abated. Again, the suffocative cough of bronchitis rarely ends in vomiting, 
which is common in the cough of pertussis. 

The only other disease with which there is much likelihood of confound- 
ing pertussis is bronchial phthisis. The points of differential diagnosis are 
the following : the one epidemic and spreading by contagion, the other non- 
contagious and isolated ; the one embraced in three distinct stages and much 
shorter, the other chronic and presenting no stages, but commencing with 
mild, non-febrile symptoms and progressively becoming more severe ; in the 
one an absence of symptoms in the intervals of the cough, provided that 
there be no complication ; in the other constant symptoms, such as are com- 
mon in tubercular disease. The previous health and the presence or absence 
of a tubercular cachexia should be considered in determining the nature of 
the disease. Usually in bronchial phthisis the lungs are also affected, so that 
auscultation and percussion may furnish positive proofs of the nature of the 
cough. 

The attacks of suffocative cough which are produced by the lodgement 
of a foreign body in the larynx or lower down in the air-passages bear a 
close resemblance to those of pertussis. The diagnosis can be made by the 
history, for in the one case there is a preliminary catarrhal stage, and in the 
other the cough begins abruptly, and usually after the known swallowing of 
the offending substance, which produces dyspnoea and a spasmodic cough as 
soon as it enters the larynx. The presence of the body can also be deter- 
mined in a large proportion of cases by the laryngoscope and auscultation. 

Prognosis. — A larger proportion doubtless recover under the better ther- 
apeutics of the present time than in former years. According to Hirsch 
(ii. p. 105), 72,000 persons perished from this disease in England and Wales 
between 1848 and 1855, or 1 in every 40 who died ; and Wilde's reports 
show that it stands fifth as regards mortality among the epidemic diseases 
of Ireland. In New York City, during the half century ending with 1853. 
4840 died of pertussis, or 1 died from this disease in every 76 of deaths 
from all causes. 

As a rule, the older the child the better the prognosis. Young infants 
may die of suffocation due to the glottic spasm. Eclampsia with extreme 
passive congestion of the encephalon is a not infrequent complication in chil- 
dren under the age of five years, and it is apt to terminate fatally. It may. 
however, be averted in most cases by proper treatment when threatening. 



390 CONSTITUTIONAL DISEASES. 

In rare instances death may occur in or immediately after a paroxysm of 
coughing, in consequence of rupture of a cerebral or meningeal vessel and 
the effusion of blood, or from stasis and coagulation of blood in the venous 
system, especially if convulsions have supervened upon frequent and pro- 
tracted paroxysms of coughing. Other complications which are likely to arise 
under conditions which favor their development, and which greatly increase 
the danger aud render the prognosis unfavorable, are capillary bronchitis, 
pneumonia, diphtheria, and in the summer season intestinal catarrh. 

Feebleness of system and antecedent and accompanying chronic disease 
increase in danger. Pertussis sometimes produces so much emaciation and 
loss of strength, in consequence of the severity and frequency of the cough 
and the repeated vomiting, that intercurrent diseases, which in favorable 
states of the system would probably end in recovery, are very apt to prove 
fatal. 

I usually inform the family that the patient is doing well if he seem 
entirely well between the paroxysms ; but if he appear ill, whether with som- 
nolence, fretfulness, fever, loss of appetite, accelerated breathing, or diarrhoea, 
he is not doing well, and probably has some complication which requires 
attention. 

Treatment. — In the catarrhal stage the treatment should be the same 
as in mild idiopathic bronchitis. Demulcent and soothing cough mixtures 
are required. Care should be taken to employ nothing which reduces the 
strength or impairs the general health. If there be much bronchitis with 
accelerated breathing and frequent cough, mild counter-irritation to the chest 
and the use of the oil-silk jacket are proper. 

Therapeutic measures are chiefly indicated in the second stage or that 
of convulsive cough. Proper treatment may control the severity of the 
cough, and abridge the duration of the second stage, and prevent or control 
complications. Pertussis has received a great variety of treatment. The 
enumeration of the medicines and modes of treatment which have had their 
season of repute and been employed by intelligent physicians would occupy 
too much time. The treatment should vary in some respects according to 
the case, but a small number of medicines suffices even in the most severe and 
obstinate forms of the malady. Knowledge and appreciation of the patho- 
logical state in pertussis assist us to the choice of the proper remedies. The 
specific principle of pertussis produces but little depression of the vital pow- 
ers. It does not impair the appetite by its direct action on the nutritive 
function, nor does it produce those profound blood-changes which we observe 
in scarlet fever and diphtheria. It affects the system injuriously by the sever- 
ity of the cough, the vomitings and consequent loss of nutriment, and the 
complications which frequently occur, some of which involve fatal conse- 
quences. 

Remedies are required which diminish the sensitiveness of the laryngo- 
tracheal surface, which destroy the specific principle in those parts where the 
local manifestations of the disease occur, or control its action ; that is. in the 
larynx and trachea, The use of inhalations is at once suggested as most 
likely to fulfil the indications, since by inhalation the medicine employed is 
brought into immediate contact with the parts which are chiefly concerned 
in the disease. 

Carbolic Acid. — During an epidemic of pertussis a few years since in the 
New York Foundling Asylum, after trial of the older remedies without any 
marked result, carbolic acid, half a drachm to eight ounces of glycerin and 
water, was employed by inhalation from three to six minutes, and at intervals 
of two to six hours according to the severity of the cough. The result was 
apparently better than with the other remedies, since the cough became less 



. PERTUSSIS. 391 

frequent and severe. Carbolic acid seems to have an anaesthetic effect on 
the laryngotracheal surface. It is also an efficient antiseptic and germicide 
agent, so that if inhaled frequently it probably destroys the specific principle 
in the mucus and epithelial cells of the air-passages. It has been in my 
practice conveniently employed in the croup-kettle. Three teaspoonfuls of 
the saturated solution of carbolic acid are added to water sufficient to cover 
the bottom of the croup-kettle to the depth of two inches, and when it is 
brought nearly to the boiling-point, the vapor is inhaled a few minutes every 
hour or second hour through the tube. If an equal quantity of the oil of 
eucalyptus be added, the inhalations are more agreeable and the germicide 
effect is probably increased. Dr. Keating 1 recommends the following formula 
for inhalation : 

R. Acidi carbolici cryst., gr. iij ; 

Sodii biborat., 

Sodii bicarb., da. gr. x ; 

Glycerini, 
Aquse, da. %j. 

x\n alkali, as in the above mixture, is believed to render the mucus more 
fluid, and water, even when not medicated, increases its fluidity and renders 
expectoration more easy. Pick also highly recommends carbolic acid in the 
treatment of pertussis (Archiv f. Kinderheilk., 1886), and believes that when 
not effectual it is too much diluted. He adds fifteen to twenty drops to a roll 
of cotton, which is introduced into a mask. The patient inhales the vapor 
of the gas several times each day, and the cotton wadding is renewed three 
times. The duration and severity of the disease were diminished by the 
inhalation, and no ill results occurred in any case. Miller has also used car- 
bolic acid internally in doses of one minim in children over the age of five, 
with, he states, good results ; but its use by inhalation appears to be equally 
or more effectual, and is devoid of the risks which attend its internal use 
{Medical Register, 1888). 

Cocaine. — This has been quite largely used as an application to the throat 
on account of its anaesthetic effect, but its action is evanescent, so that in 
order to obtain the full benefit from its use it is necessary to apply it often. 
Labrie states that the repeated application to the throat of a 5 per cent, 
solution immediately diminishes the number of paroxysms (Lond. Med. Bev., 
1888). Holt, in discussing the safety of its use (iV. Y Med. Journ., 1888), 
states, " 1st. It must be used with great caution in young children under all 
circumstances ; 2d. The spray is never to be recommended, since an uncertain 
quantity is given ; 3d. Solutions stronger than 4 per cent, should not be used 
in children under two years ; 4th. In cases where it was tried he failed to see 
any notable benefit." Probably cocaine will not come into general use, because 
frequent applications would be necessary in order that its effect be continuous, 
and this would apparently be dangerous ; still, it might be occasionally used 
in order to obtain temporary respite from the cough when it involves danger 
in consequence of its frequency and severity. 

Antipyrine. — This agent is now largely used, and many physicians have 
written in its favor. Sonnenberger regards it as a specific (Tlierapeut. Monat- 
schrifte, 1888). He prescribes it in doses of as many centigrammes (one-sixth 
grain) as the child is months old, and as many decigrammes (one and a half 
grains) as it is years old, three times daily. He says that the earlier it is 
employed the better is the result. Genser administers only one and a half 
grains daily for each year of the age, and he found that it diminished the 
frequency and severity of the cough (AUgemeine med. Cent. Zeit., 1888). 

1 Medical News, Feb. 28, 1885. 



392 CONSTITUTIONAL DISEASES. 

Laborderie reports the complete cure of pertussis by the use of antipyrine 
in twelve to sixteen days. He says : " (1) Children take antipyrine without 
difficulty, and as a rule easily bear its effects ; (2) The spasmodic condition 
is rapidly calmed, and in a few days the disease declines ; (3) Its action is so 
prompt and free from accidents that it becomes a valuable remedy in a malady 
which may be of prolonged duration and give rise to many complications " (Bull. 
gen. de Therap., 1888). In my practice antipyrine has also in some cases been 
a very important remedy, reducing the severity of the paroxysms. I have 
administered it in small or moderate doses every third or fourth hour in com- 
bination with an alcoholic stimulant. Antipyrine is especially useful in cases 
attended by fever. But the use of antipyrine is attended by some danger. 
and it should be discontinued if depression or lividity occur. An editorial in 
the Montreal Med. Journ., Oct., 1889. states that antipyrine, besides being dan- 
gerous, exerts no controlling effect over pertussis. 

Quinine. — The use of quinine in whooping cough was strongly recom- 
mended by Binz, who attributed the good effects which he had observed to 
its germicide action. It has been employed with apparently good results, 
both locally and internally. Kolover prescribes the following solution as a 
spray : 

R. Quiniae sulph., gr. 50; 

Acidi sulphur., gtt. 30 ; 

Aquae destillat., ^5f . 

The fauces are sprayed with this every two hours for the first three days, and 
three hours for the rest of the week, when treatment is no longer necessary 
(X' Union Med., 1887). Bachen employs insufflation into the nostrils of fifteen 
grains of a finely triturated powder of twenty parts of quinine and one of 
benzoin (Lond. Med. Rec, 1887). Swett also prescribed the insufflation of 
quinine morning and evening, and observed improvement after the first day. 
Forchheimer and the late Prof. Rochester have likewise recommended the 
local use of quinine. The internal use of quinine has been supposed to be 
useful by diminishing reflex irritability (Schlakow and Eulenberg). It is 
undoubtedly a useful remedy in those common cases in which febrile symp- 
toms arise from bronchitis or broncho-pneumonia. 

Paulet 1 recommends the evaporation, over a suitable fire, of 

R. Spirits of thymol, grammes 10 

Alcohol, " 250 

Water, " 750 

Keating also recommends the same agent in the following formula : 

R. Thymol., gr. xv ; 

Alcoholis, .^iij ; 

Glycerini, ^ss ; 

Aquae, '^xxxiv. — Misce. 

Internal remedies, formerly much used, now occupy the second place in 
the therapeutics of pertussis. Belladonna has been largely employed, since 
it appears to diminish the spasmodic element in the cough of pertussis. 
Brown-Sequard, in remarks made before the United States Medical Associa- 
tion in May, 1860, maintained that the duration of pertussis, so far as its 
nervous element is concerned, might be abridged to a few days by doses of 
atropia sufficiently large to cause toxical effect ; but in one case which I saw 

1 London Medical Record, May 15, 1884. 



PEBTUSSIS. 393 

in consultation, in -which one teaspoonful of tincture of belladonna was given by 
mistake to a child of about three years, the subsequent cough, though mild, did 
not lose its spasmodic element. Children require a larger proportionate dose 
of belladonna than adults, and it can be safely administered in gradually in- 
creasing doses until physiological effects are produced, when some mitigation 
in the cough may be expected. Probably the action of the drug is on the 
respiratory centres in the medulla, and not directly on the muscles of respira- 
tion. The effect of belladonna in controlling the spasmodic cough is most 
marked when physiological symptoms are produced, and some children require 
larger doses than others. Thus I gradually increased the doses of belladonna 
to twelve drops for a child of three and a half years who had severe pertussis, 
without producing the characteristic efflorescence, while smaller doses from 
the same bottle produced this effect in older children. Rarely I have discon- 
tinued the belladonna on account of diminished flow of urine, which this 
agent may or may not have produced, and very rarely on account of suddenly 
developed muscular weakness, which 1 had reason to think the belladonna 
caused. This occurred in the case alluded to above in which twelve drops 
of the tincture were given, so that the muscles seemed flabby and the trunk 
and head were supported with difficulty. The tincture of belladonna is con- 
venient for use, and most of that in the shops is active and reliable. The 
doses which I ordinarily found to be sufficient when prescribing belladonna 
for pertussis, and which also produced efflorescence, were as follows : to a 
child of two years three drops, and to one of six or eight years eight or 
ten drops, morning and evening. I always, however, commenced with a 
smaller number, and continued to administer the dose which produced the 
local effects alluded to, unless the cough were moderated by smaller doses. 
In the majority of cases I have noticed no decided effect till the rash was 
produced, when the symptoms improved, the cough becoming less frequent 
or less severe. By the belladonna treatment the spasmodic stage may not 
only be rendered mild, but be abridged to two or three weeks. In some 
cases the severe cough begins to yield almost immediately under full 
doses of this agent, but in other cases its continuance for some days is 
necessary, with other remedies as adjuvants, before there is any appreciable 
benefit from its use. But since the germicide treatment of pertussis has 
come into use, it is probable that belladonna will in a measure be superseded 
by those agents which are believed to exert a destructive effect on the sup- 
posed cause. 

Sulphur. — Much benefit is said to result from fumigating the room occu- 
pied by the patients with burning sulphur. The children having the disease 
are attired in clean clothes and removed, and the room which they have occu- 
pied, containing the furniture, clothes, and toys, is fumigated five hours with 
burning sulphur, after which the doors and windows are thrown open. The 
children sleep in the same room during the following night. Immediate 
improvement is said to follow. This treatment of pertussis is recommended 
by Manby, Gelhert, Mohn, and others. 

The distinguished Brazilian physician Moncorvo advises, and uniformly 
employs, local treatment with a solution of resorcin. In an interesting paper 
read before the Pediatric Section of the Ninth International Medical Con 
gress in 1887 he states that he employs resorcin as a local antiseptic on 
account of its slight irritating properties, its great solubilit\ r , and its absence 
of odor. Beginning with a 1 per cent, solution, he had increased it to 8 per 
cent. He first applies to the periglottic region a 10 per cent, solution of 
hydrochlorate of cocaine, which diminishes the reflex excitability of the 
laryngeal mucous membrane and renders the paroxysms less frequent, and 
then applies the resorcin. I have largely employed a 10 per cent, solution 



394 CONSTITUTIONAL DISEASES. 

of resorcin as a spray from a barrel atomizer every hour to two hours. It is 
not unpleasant, and is apparently useful. I continue to use it as one of the 
most efficient remedies. 

Another apparently good remedy for pertussis is bromoform. This is a 
clear fluid not disagreeable, with a specific gravity of 2.9, chemical formula 
CHBr 3 . Steppe employed it in 70 cases of whooping cough in children. 
In a few days the paroxysms diminished, and in three weeks the patients 
were well. 

Cresoline, a product of coal-tar, having the formula C 6 H 5 CH 3 0, vaporized 
in the nursery by a flame underneath, also has its advocates. 

Most of the remedies mentioned above have apparently been sufficiently 
employed to justify the belief that when judiciously prescribed they diminish 
the severity and duration of the paroxysmal stage of pertussis. Additional 
observations are required in order to determine the comparative efficiency of 
each. 

Since the paroxysms are likely to be more severe at night, and the patient 
consequently is deprived of the required sleep, a medicine is needed which 
will procure some hours of rest and thereby diminish the number of parox- 
ysms. For this purpose the hydrate of chloral is especially useful, given in 
doses of two to five grains according to the age. and perhaps repeated. It 
does not seem to me that chloral exerts any marked influence upon the 
cough ; it appears to be useful chiefly in the manner stated — to wit, by pro- 
curing prolonged sleep. 

One of the chief dangers from pertussis we have seen to be the occur- 
rence of passive congestion of organs, especially of the brain, with the 
liability to hemorrhages, serous effusion, and eclampsia. This is in great 
part prevented by the action of the medicines mentioned above, which 
diminish the severity of the cough or its frequency. But when there are 
great and frequent congestions of the nervous centres, producing eclampsia 
or premonitions of eclampsia, the use of one of the bromides is indicated for 
its prompt and decided action in averting the danger. Even if the symp- 
toms be not urgent, its tranquillizing effect, and especially its prompt action 
in diminishing reflex irritability, render it one of the most useful agents in 
pertussis. If there be sudden twitching of the muscles, marked stupor, 
headache or fretfulness, or adduction of the thumbs across the palms of the 
hands during the cough, I never fail to give the bromide of potassium in 
sufficiently large and frequent doses ; and now eclampsia occurs much more 
rarely in a case which I treat from the commencement than in former 
years. 

The complications of pertussis require prompt treatment. Whenever 
the child feels ill between the paroxysms, he should be carefully examined, 
and some complication will probably be found which requires treatment. If 
the bronchitis have increased so as to become a complication or pneumonia 
have arisen, the whole chest should be covered with a light flaxseed poultice 
containing one-sixteenth part of mustard, while quinine and ammonia with 
alcoholic stimulants are given at regular intervals. Ammonia carbonate dis- 
solved in teaspoonful doses of water and given in milk will be found useful. 
Cerebral accidents are best arrested by the warm foot-bath, cold to the head, 
and by the bromide or chloral. 

Diphtheria not infrequently supervenes as a complication in a locality 
where it is endemic or epidemic, and if mild it is often overlooked. Recently 
I have seen a case in which diphtheria complicating pertussis had continued 
four days, without being recognized by the attending physician, the symp- 
toms being attributed to other causes. The diphtheritic patch in these cases 
appears upon the well-known sore under the tongue, in addition to its occur- 



MUMPS. 395 

rence upon other parts. The secondary form of diphtheria requires the same 
treatment as the primary form. 

Hauke in 1862 published experiments which showed that both carbonic 
acid and ammoniacal vapors when inhaled increase the cough, while the inha- 
lation of oxygen produced no cough and was agreeable to the patient. Hence 
children in close and crowded apartments suffer most severely from pertussis, 
and those who are taken to parks or the country, where vegetation absorbs the 
carbonic acid, not only obtain benefit from the general invigorating influence, 
but also as regards the cough. The fact that fresh and pure air benefits the 
cough has indeed long been known, and has influenced practice, for patients 
are almost universally allowed to be much of the time in the open air and are 
taken to the parks and upon excursions. Nevertheless, caution in this regard 
is required, for exposure in wet weather or to sudden changes of temperature 
is very likely to develop bronchitis or pneumonia. 

Prophylaxis. — Pertussis is very contagious, and it appears to be, in nearly 
all instances, if not in all, contracted by inhaling the breath of the patient. 
I have never observed a case in which it seemed to be communicated through 
a third person, and it is not, I think, usually contracted by children living in 
the same house if there be no personal contact. There is not, therefore, that 
urgent need of personal disinfection and of caution on the part of the phy- 
sician and nurse in their subsequent intercourse with healthy children, as in 
the case of the eruptive fevers. 



CHAPTER IX. 
MUMPS. 

Synonyms. — Parotitis. Parotiditis. — Mumps is a constitutional or blood 
disease with local manifestations. It occurs chiefly in childhood, youth, and 
early manhood, cases being rare in infancy and old age. Its chief character- 
istic, by which it is readily recognized, is inflammation of the salivary glands, 
causing swelling and tenderness. 

Etiology. — This disease is highly contagious, and it commonly occurs as 
an epidemic. It is usually communicated through the air, which is tainted 
by the breath or by exhalations of a patient, but cases are recorded in which 
it seems to have been communicated by a third person or by infected articles. 
Thus Roth relates a case in which it appears to have been communicated by 
a physician, and another case in which it was attributed to the use of bedding 
in which a patient with mumps had slept (Bost. M. and S. Journ., 1887). 

Mumps is probably a microbic disease. The investigations of Ollivier are 
confirmatory of those of Capelan and Charin on the occurrence of peculiarly 
shaped micrococci in the blood and urine of patients with mumps (Halde- 
mann, in the Journ. Am. Med. Assoc, 1887). Pasteur found in the blood in 
mumps rod-shaped bacteria one millimetre broad and two millimetres long, 
but attempts to inoculate animals were fruitless (Annual of Med. Sci., vol. i., 
1889). 

Incubation. — Dr. Dukes states that the incubative period appeared to be 
from sixteen to twenty days in 32, and perhaps 31, of 42 cases. Henoch believes 
that the incubative period is usually about fourteen days. Goodhart relates 
a case which occurred fourteen days after exposure, and in two others the 
incubation appeared to be twenty-one days. Ringer says that the incubative 



396 CONSTITUTIONAL DISEASES. 

period varies from eight to twenty-two days. Flint says that the incubation 
varies from ten to eighteen days. Bristowe states that the average is about 
fourteen days ; and his opinion, I think, is correct. 

Symptoms. — Mumps begins with languor and fever, the temperature in 
some cases rising to 103°, and if the fever be considerable headache and 
vomiting are common. In a few hours, usually as early as the first visit of 
the physician, the patient complains of pain and tenderness in the depression 
below one ear and posterior to the ramus of the jaw. Notwithstanding the 
fever, the features are often pallid. Along with the pain and tenderness, 
swelling begins in the site of the parotid gland on one side, and more fre- 
quently, it is said, on the left than right. In most instances the swelling soon 
begins upon the opposite side, so that the disease is bilateral. Exceptionally, 
it begins on the two sides simultaneously. Rarely only one side is affected. 
The swelling gradually increases ; it fills the depression under the ear, ex- 
tends forward and upward upon the cheek, and downward to a greater or less 
extent upon the neck. It reaches its maximum from the third to the sixth 
day. The most prominent point at this time is immediately underneath the 
lobule of the ear, which is pressed outward by the swelling of the gland. The 
tumor yields on pressure, but is elastic and tense, and the fulness immediately 
returns when the pressure is removed. The skin covering it preserves its 
normal appearance or it presents a faint blush. The fever, more or less intense, 
does not usually continue more than two to four days, but occasionally it re- 
mains longer. The pressure which movements of the jaw and of the pharyn- 
geal muscles produce on the gland renders mastication, swallowing, and even 
speech, painful and difficult. The submaxillary glands, and also the sublin- 
gual, are occasionally involved, so that the features are greatly disfigured by 
the swelling. The swelling is at its maximum between the third and sixth 
days, after which it begins to decline, and between the tenth and twelfth days 
it has entirely disappeared. 

Occasionally, during an epidemic of mumps, we observe cases in which 
the parotids are but slightly or not at all affected, and the chief manifes- 
tations of the disease are in the submaxillary glands, which undergo the 
characteristic inflammatory changes. Rarely the tonsils are also tumefied. 
Free perspiration occurs in certain patients at the commencement of conva- 
lescence. 

Anatomical Characters. — The opinion expressed by Tirchow has been 
generally accepted, that inflammation of the gland-ducts occurs, with conse- 
quent oedema of the connective tissue. The oedema extends also to the con- 
nective tissue adjacent to the gland. 

Complications ; Sequelae. — The swelling of the salivary glands some- 
times suddenly abates, and in the male the testicles and epididymis, and in 
the female the mammary glands or ovaries, are involved, with sometimes more 
or less oedema of the labia majora. Occasionally these inflammations, which 
are less frequent in young children than in those nearer the age of puberty, 
when the sexual organs are becoming more developed, occur without subsid- 
ence of the parotid swelling. They cause considerable increase in the fever 
and constitutional disturbance, but with proper treatment decline in six or 
eight days, pursuing the same course as the parotid inflammation. Some- 
times repellant applications to the neck appear to produce the metastasis, as 
in the following case: On March 19, 1877, I was requested to see a young 
gentleman of eighteen years. He had been well till March 14th, when he 
complained of pain below his ears, and his mother applied a towel wrung out 
of cold water around his neck. On the following day slight swelling was 
observed under the angle of the lower jaw on the right side (submaxillary 
gland), and the cold application was continued. On the 17th the swelling 



MUMPS. 397 

had disappeared, but the fever and headache had greatly increased, so that 
he was compelled to lie in bed. On the 19th, at my first visit, he had such 
violent headache and was so intolerant of light and noise that I greatly feared 
that he had acute encephalitis. All swelling under the ears was gone ; the 
left testicle was tender and beginning to swell ; axillary temperature 102°. 
The cold cloths were removed from the neck and applied to the head, and 
potass, bromid.. gr. xxv. administered every third hour. 20th. Axillary 
temperature 104° ; symptoms unabated and alarming. Ordered six leeches 
to be applied upon the temples and left groin, and a purgative, and two 
drops of the tincture of aconite to be given with each dose of the bromide. 
21st. Temperature 103°. States that numbness and a pricking sensation 
which he had felt in both legs during the last forty-eight hours had ceased 
(possibly from the aconite). 23d. Is convalescent ; has no return of the 
swelling under the ears and the orchitis has abated. 

Several writers mention the fact that in rare instances orchitis precedes 
the parotiditis. Thus, Eustace Smith mentions a case in which the orchitis 
preceded by sixteen hours the symptoms referable to the salivary glands. 
The complications alluded to which involve the sexual organs occur more 
frequently at puberty or in youth than in childhood. 

It is said that deafness sometimes occurs during mumps, due to extension 
of inflammation along the Eustachian tube to the middle ear, and if the treat- 
ment proper for otitis media be employed this form of deafness abates. 
Dalby mentions another form of deafness which comes on suddenly, and is 
supposed to be due to injury of the auditory nerve, since no appreciable lesion 
of the auditory apparatus is observed. The impairment of hearing in this 
form of deafness is likely to be permanent. 

Diagnosis. — If the physician have seen but few cases of mumps, there 
is danger that he may mistake the swelling for an inflamed cervical gland, or 
vice versa ; but an inflamed cervical gland presents to the finger a hardness 
almost like that of cartilage, and it is circumscribed or round, and does not 
invest the ear. These characteristics contrast with the elasticity, seat, and 
shape of the parotid swelling, which extends forward upon the cheek and 
surrounds and elevates the lobule of the ear. Tumefaction resulting from 
diphtheritic or any other form of faucial inflammation, or from periostitis 
affecting the root of the posterior molar, may be detected by examining the 
fauces and interior of the mouth. Inflammation of the parotid sometimes 
occurs in debilitated states of the system, as in or after severe typhoid fever, 
scarlet fever, measles, etc. Occurring under such circumstances, the gland 
usually suppurates. The differential diagnosis between this form of parotid- 
itis and mumps can be made by the history of the case, because mumps 
rarely occurs as a complication of another disease and does not cause sup- 
puration. 

Prognosis. — The result as regards life is favorable. The orchitis, if 
bilateral, sometimes destroys the virility of the individual. Permanent im- 
pairment of hearing may also occur, as stated above. 

Treatment. — This is simple. In ordinary cases it suffices to cover the 
swelling with oakum or carded wool. If the tenderness or pain be consider- 
able, the gland should be covered with spongiopilin soaked in water, and 
gently rubbed with tincture of belladonna and glycerine in equal parts. If 
the patient have severe headache, with high temperature, more active meas- 
ures are required, especially if delirium be also present. Saline laxatives 
should be given, a warm general bath or mustard foot-bath employed, and 
antipyrine with one of the bromides prescribed. The following prescription 
will be useful for a child of ten years : 



398 CONSTITUTIONAL DISEASES. 



R. 01. cinnamom., 


gtt. v ; 


Phenacetin, 


Bij; 


Sodii bromidi, 


31SS; 


Cafieini (alkaloid), 


gr. x ; 


Sacchr. lactis, 


3j. — Misce. 



Divid. in chart JSo. x. Give one powder every three hours in headache or fever. 

The rise of temperature is a premonitory warning of a complication, espe- 
cially of orchitis in the male, and the early application of a poultice diminishes 
its severity. If a complication occur, fomentations should be constantly 
applied over the inflamed part, and phenacetin or antipyrine given at regu- 
lar intervals to reduce the fever. 



SECTION III. 
OTHER GENERAL DISEASES. 



CHAPTER I. 



INTERMITTENT FEVER. 



This is a constitutional malady produced by an organism which exists in 
marshy soil. I have notes of 36 cases of this disease occurring under the 
age of three and a half years. Several of these patients were treated in 
private practice, and the rest in institutions with which I have been con- 
nected. In children above the age of three and a half years intermittent 
fever differs but little from that of the adult, while in those under this age 
it presents certain peculiarities. Of the 36 cases which I have observed, 19 
had the quotidian form, 10 the tertian, 2 the tertian becoming afterward 
quotidian, 1 the quotidian becoming afterward tertian, while in the remain- 
ing 4 cases the form of the disease is not stated. In quotidian ague the 
malaria has been supposed to act more powerfully on the system or the sys- 
tem is more susceptible to its influence than in the tertian form, and hence 
the fact that the quotidian is the prevailing type of ague in tropical regions, 
where vegetation is luxuriant, marshes extensive, and the heat intense. 
According to this theory, the feeble resisting power in the system of the 
infant explains the fact that it has quotidian more frequently than tertian 
intermittent, although the latter is much more common in the adult in this 
climate. 

Facts demonstrate that infants sometimes receive intermittent fever from 
their mothers. If mothers during gestation have malarious cachexia, their 
infants, whether born at full time or, a» often happens, prematurely, are apt 
to be small, thin, and feeble, and occasionally they have soon after birth dis- 
tinct paroxysms of the ague. Dr. Stokes related the case of a pregnant 
woman with ague who believed that she noticed periodical tremors of her 
foetus, but I suspect that she was mistaken as regards the cause, for the 
paroxysm of intermittent in young children is not ordinarily accompanied 
by tremors. 

The youngest infant in my practice who apparently derived the ague from 
its mother, and probably through the foetal circulation, had the following his- 
tory : Its mother had occasional attacks of tertian intermittent during the 
two years preceding her confinement, and her baby when one week old was 
observed to have the same disease, occurring also each second day, the cold- 
ness and blueness in the first stage of the paroxysm lasting from half an hour 
to one hour. 

It is not fully ascertained whether a nursing infant may contract inter- 

399 



400 



COXSTITUTIOXAL DISEASES. 



mittent fever by lactation, but if it be admitted that it is sometimes com- 
municated to the foetus through the maternal circulation, it does not seem 
improbable that the specific principle occasionally enters the milk as well as 
other secretions. I have frequently remarked the presence of the disease in 
nursing infants whose mothers were affected, and in one instance an infant at 
the breast, whose mother had the ague, having contracted it in a suburban 
village, but now living in a non-malarious part of the city, presented evident 
symptoms of the disease. Similar observations by Frank, Burdel, and others 
do not indeed fully prove the communicability of intermittent fever by lacta- 
tion, but render it highly probable. 

The period of incubation in the infant varies greatly, as in the adult. 
When the malaria is concentrated and unusually active or the condition of 
system is favorable for its reception, the disease may commence soon after 
exposure. Thus, in tropical regions travellers exposed for a single night have 
been known to sicken within twenty-four hoars, but in our cooler latitude a 
longer incubative period is the rule. In the infant, however, in our climate, 
intermittent fever often begins in a very short time after exposure, though 
there may be an incubative period of some weeks. The following have been 

my observations relating to this point : A. M , female, eight months old, 

remained two days on Long Island in October, 1870, and three days after her 

return to the city a quotidian commenced. P. S . male, eleven months 

old, remained three days on Long Island, and a quotidian commenced four 

clays after his return. K , nine months old, remained on Staten Island 

one week, and eleven days after his return a tertian commenced. Gr. Im- 



aged three years, remained a day and a night on Staten Island in 1870 ; three 
weeks afterward intermittent fever commenced, preceded by a week of lan- 
guor. A. U , female, aged two years and two months, had the first 

paroxysm of a tertian two and a half weeks after returning from a visit 
of one week in Hoboken. As there was no malaria in the portions of the 
city where these infants resided, the incubative periods are nearly ascertained. 
Etiology. — The cause of the fevers, intermittent and remittent, due to 
marsh miasma, is an organism, designated the plasmodium malarias. Hun- 
dreds of microscopists had previously searched for the malarial microbe in 
vain, when it was discovered in 1880 by M. Laveran, a French army surgeon 
in Algeria. He was successful in the discovery because the technique em- 
ployed by him differed from that of his predecessors. The plasmodium is 
the most interesting and remarkable pathogenic body yet discovered in the 
blood. The following figures, representing stages of its development, are 
copied from the paper by Dr. Manson, published in the London Lancet. Jan- 
uary 6, 1894. Fig. 51 represents a red blood-corpuscle, having in its inte- 



Fig. 51. 



Fig. 52. 



Fig. 53. 






rior a pale body with ill-defined edges. Within this body are very black 
particles which, closely examined under the microscope, are seen to be 
moving, so as to change their relation to each other. The shape of the 
shadowy body within the corpuscle also changes. Fig. 52 represents a 



INTERMITTENT FEVER. 



401 



similar body which, instead of being intercellular, floats free in the blood- 
plasma. Fig. 53 represents circular disk-shaped bodies, transparent except 
at their centres, where very black granules are aggregated, some of which 
o-ranules are agitated and moving. Some of these transparent bodies are 
inrracorpuscular and surrounded by a rim of haemoglobin, but most of them 
float free in the plasma, and are designated by Manson " centrally pigmented 
disks." Fig. 54 exhibits a body similar to the last, but with a properly 



Fig. 54. 



Fig. 55. 






Fig. 56. 



adjusted microscope the pale peripheral substance external to the black 
granules is seen to be arranged in leaflets, so as to resemble the petals of the 
daisy. These ki rosettes 1 ' occur both within cells and free in the blood- 
plasma, but are not common. Fig. 55 represents another view of the Plas- 
modium — to wit, crescenta, with the horns rounded, and in some cases an 
indistinct shadowy body lying in the cup 
or upon the concave surface with its edge 
presenting the appearance of a line with its 
convexity outward. 

Fig. 56 represents a form of the Plas- 
modium which has most remarkable cha- 
racteristics, and is apparently very harmful 
to the blood. 

I can do no better than quote Manson's 
graphic description of this remarkable form 
of the malarial parasite. Says he : u Some- 
times in searching through a slide of mala- 
rial blood, at a particular point of the field 
you will see one or more of the blood- 
corpuscles moving about a little and agi- 
tated without any evident cause. If one 

of the corpuscles happens to be standing on edge, you may see it bend over 
upon itself as if pressed down by some force, and then spring up again as if 
this force had been removed. Sometimes in such a slide you will see one or 
more of the corpuscles crushed up, as it were, or dashed aside and tumbled 
about. If now you turn on the high power and inquire as to the cause of 
this disturbance among the corpuscles, you will be brought face to face with 
one of the most striking of the many strange sights the microscope reveals 
to us. Imagine a microscopic cuttle-fish, or octopus, with a clear globular 
body in which a number of rather large black piquant particles are tumbling 
and chasing each other about in a state of incessant motion. Imagine, also. 
proceeding from and attached to this body one, two, three, or four long, slen- 
der arms, each of them three or four times the length of the diameter of a 
blood-corpuscle, and all these long cuttle-fish-like arms whirling about like so 
many whiplashes or flails in a state of frantic activity. This is what is 
known as the ' flagellated organism of malarial blood.' The long arms 
thrust the corpuscles about, double them up, coil around them, squeeze 
26 




402 CONSTITUTIONAL DISEASES. 

theru out of shape, and treat them like so many india-rubber balls. Occa- 
sionally one of the arms breaks away from the spherical body it was attached 
to. It swims about, wriggling its way among the corpuscles, and quickly 
passes out of the field. Some one of the arms coils itself up or starts into 
an extended position, shivering like a wand when it is struck." 

The relation of these forms of the plasmodium to each other is still a 
matter of conjecture. Manson believes that the "rosette" form is the ma- 
tured organism, and that the petals of the rosette are the germs, some of 
which, as they separate, enter the red blood-corpuscles, and others remain in< 
the plasma, where they develop. It is believed by him that the bronzing of 
the tissues which occurs in severe cases, attended by recurrences, is caused 
by the pigmentary matter which, developed in the organisms which we have 
described above, are conveyed to the different tissues. The periodicity of the 
fevers due to marsh miasm requires explanation. That a fever produced by 
an animal parasite should be quotidian, tertian, or quartan cannot, in our 
present knowledge, be satisfactorily explained. Another subject requiring 
explanation is the fact that one affected by the malarial miasm remains so 
long under its influence, so that attacks of malarial fever recur even under 
circumstances favorable for its elimination. Thus a child of ten years had 
every year for seven years attacks of intermittent fever. The disease was 
contracted at the age of three years in Harlem, and the subsequent residence 
of the family had been in a part of the city where no malaria exists. 

Symptoms. — In infancy, and especially prior to the age of eighteen 
months, the symptoms differ in certain respects from those which characterize 
the malady in the adult, and are universally known. In childhood the symp- 
toms are similar to those in the adult, and need not therefore be described in 
this connection. 

In the infant the type, as we have seen, is quotidian, with now and then 
a tertian. Advancing beyond the age of eighteen months, we meet more and 
more cases of the tertian type, and in childhood the tertian is the common 
form. I have known the quotidian in the infant, when cured, to reappear a 
few weeks later as a tertian : but ordinarily it remains quotidian, unless the 
patient has reached the age at which the tertian type predominates. 

The paroxysm in the young infant presents three stages, as in the adult, 
but while the second, or febrile, is well marked, the first and third are much 
less pronounced. The patient does not shake (exceptionally one does even 
within the first year) in the first stage, but a slight tremor may or may not be 
observed. The countenance presents a sunken appearance, the lips and fingers 
are livid, while portions of the surface not livid are pallid, with the goose- 
flesh appearance, which is, however, less marked than in children of a more 
advanced age. The blood leaves the surface, which consequently shrinks, 
while it accumulates in the veins and internal organs ; the pulse is feeble and 
readily compressed ; the surface grows cool from the diminished supply of 
blood, but the breath is warm, and the internal temperature, so far from being 
reduced, is elevated two or three degrees. The parents may be alarmed at the 
sudden sinking of the vital powers and seek medical advice, but in other 
instances the first stage is so slight that it passes unperceived till they have 
been taught to watch for it. 

In the second or febrile stage, which immediately succeeds, the pulse 
becomes full and rapid, 120 to 130 or 140 beats per minute, and the external 
as well as internal temperature is elevated as in few other diseases (104°- 
108°). The face is flushed, surface dry, and head painful, as evinced by the 
features. This stage lasts about two or three to six or eight hours. The 
third stage, or that of perspiration, succeeds, which terminates the suffering 
of the patient till the following paroxysm. In infancy the perspiration is not 



INTERMITTENT FEVER. 403 

abundant, and in the first half of this period is nearly absent. In the interval 
of the paroxysms the patient appears well, except a degree of languor. 

In 24 of the cases of infantile intermittent which I have treated my notes 
describe the character of the paroxysms. In 16 of these there was no chill 
or trembling in the first stage, but blueness and coolness of the extremities 
and features and sudden prostration. This stage lasted from ten minutes to 
one hour. In the 8 remaining cases the infants were observed to tremble or 
shake as in adult cases. The perspiration of the third stage was in nearly all 
cases, when observed, slight and of short duration, but in some it was not 
observed. 

During the cold stage passive congestion of the internal organs occurs to 
a greater or less extent, but the circulation is equalized during the reaction 
of" the second stage. The spleen, whose capsule is distensible, soon enlarges 
in many patients in consequence of the frequent and great congestions, con- 
stituting the - : ague cake." This enlargement is more common in children 
than adults. Since my attention has been particularly directed to this sub- 
ject I have been able to feel the enlarged spleen, by examination through 
the abdominal walls, in probably one-third of the cases under the age of ten 
years. This organ returns to the normal size after the ague is cured. From 
the intimate relation of the spleen to the composition of the blood, it is evi- 
dent that the character of this fluid must be affected if intermittent fever be 
protracted. The blood becomes more and more impoverished and a state of 
decided hydraemia supervenes. A few weeks' continuance of the ague suf- 
fices to produce decided pallor of the features and surface generally, and as 
all watery blood is prone to transudation, such patients not infrequently 
present more or less oedema of the face, ankles, and other parts. Sometimes 
also, especially under unfavorable hygienic circumstances, purpuric spots 
(purpura hemorrhagica) appear under the skin, affording additional proof of 
the change which the blood has undergone. 

In long-continued cases of malarial disease in the adult waxy degenera- 
tion of organs is apt to occur, as well as melansemia. Pigment-cells, flakes, 
and particles appear in the blood, the coats of the minute arteries, and in 
various organs, as spleen, liver, etc. In the child these results are more 
rare. 

Intermittent fever in children, if proper remedial measures are employed 
at an early period, is ordinarily not dangerous, and is quite amenable to 
treatment ; but that comparatively infrequent and fatal form of it desig- 
nated the " pernicious " occurs more frequently in children than in adults. 
In New York City, where the type of malarial diseases is mild, I have never 
met a case of pernicious intermittent in the adult, but I can recall to mind 
such cases in children, two of them fatal. This form of the fever occurs in 
a smaller proportionate number of cases in infancy than in childhood, proba- 
bly because the cold stage is less pronounced. In the pernicious ague the 
system is overpowered — it does not react in a degree commensurate with the 
intensity of the disease. The patient enters the cold stage, becomes stupid, 
and, if not relieved by prompt and efficient measures, passes into fatal coma. 
A type of the disease, therefore, which would not be pernicious in a robust 
individual may be such in one of a broken-down constitution and feeble 
reactive power. In most cases occurring in children the coma is preceded by 
eclampsia, which is apt to be general and contracted. 

Eclampsia increases the passive congestion of the cerebro-spinal axis 
already present in this stage, and if not speedily relieved may end in trans- 
udation of serum over the surface of the brain, and perhaps meningeal 
apoplexy, causing fatal coma. This has occurred twice in my practice. 

Sometimes in young children the diagnosis of intermittent fever is doubt- 



404 CONSTITUTIONAL DISEASES. 

ful, either because the disease has not continued sufficiently long or there has 
not been the characteristic paroxysm. The patient may be feverish and fret- 
ful, with anorexia and evidences of headache, but without the usual distinc- 
tive symptoms. I have sometimes in such cases been able to establish the 
diagnosis by detecting enlargement of the spleen. In examining for the 
" ague cake " the child must lie quietly on its back, and the fingers, placed 
midway between the epigastrium and umbilicus, be carried gently but with 
firm pressure outward in the direction of the spleen, when the anterior edge 
of this organ will be felt if it be enlarged. It is impossible to make the 
examination when the child cries, on account of the contraction of the 
abdominal muscles. 

Treatment. — It is evident that no time should be lost in applying appro- 
priate remedies in a case of infantile ague, for, although the first paroxysm 
may be mild, the next may be more severe and attended with danger. More- 
over, the sooner the disease is cured the less liable it seems to be to return. 
Therefore we prescribe at once the sulphate of quinia or cinchona, one and a 
half grains of the latter producing the effect of about one grain of the former. 
Our experience in the children's class in the Outdoor Department has been 
chiefly with the sulphate of cinchona on account of its cheapness, and there 
has yet been no case of ague which it has failed to control. A recent writer 
has published statistics showing his success in curing intermittent fever by 
this agent, but nothing in therapeutics is more easy than to cure this disease 
in our climate by either of the sulphates mentioned. The chief difficulty 
consists in preventing a return. To an infant of two years I prescribe one 
grain of sulphate of quinia or the equivalent of sulphate of cinchona three 
times daily, till all symptoms of the ague have disappeared ; then twice a 
day during the subsequent week, and afterward once a day for some days, 
and finally twice or thrice a week. It is only by the protracted use of the 
drug in occasional doses that the return of the intermittent fever can be 
prevented. 

It is important in administering these sulphates to infants to employ a 
vehicle which will, so far as possible, disguise the bitterness. The vehicle 
which I prefer for their administration is the elixir adjuvans, elixir tarax. 
comp., or, better still, the syrupus yerbse santaa comp. The following formula 
is for a child of three years : 

R. Quinise sulphat,, gr. xvj ; 

Syr. pruni virginiani, 
Syr. yerbse santse comp., da. §j. — Misce. 

The following is also a good formula : 

R. Quinise sulphat., gr. xvj ; 

Syr. yerbse santse comp., §ij. — Misce. 

One teaspoonful three to five times daily. 

The first dose should be given immediately after the fever abates. In this 
climate two or three days suffice to cure the disease, after which, by daily 
but gradually diminished use of medicine in the manner stated above, the 
return of the malady is prevented. Protracted cases attended by anaemia 
require the use of iron in addition to the remedy which is designed to con- 
trol the disease. 

For children with irritable stomachs, who cannot retain the salts of quinine 
which are ordinarily prescribed, the tannate may be employed in powder or 
lozenges with chocolate ; but in order to produce the same effect the dose 
must be two and a half times greater than that of the sulphate or muriate. 



REMITTENT FEVER. 405 

The protracted cachexia which follows an attack of malarial fever is best 
treated in children, as it is in adults, by arsenic, especially the liquor potassae 
arse nit., and iron. Quinine is much less efficient in curing this cachexia than 
these agents 



CHAPTER II. 

REMITTENT FEVER. 

If a physician were to consult the standard treatises on diseases of children 
in order to ascertain the nature of remittent fever, he would rise from the 
perusal with no clear idea of it. One tells us that the remittent fever of 
children is identical with typhoid fever of adults ; another, that it is a gastro- 
intestinal inflammation ; and, finally, Hillier believes that there is properly 
no such disease, and that the term should be dropped from the nosology of 
diseases of children. There is, however, a remittent fever of children as well 
as of adults, and much of the confusion which exists in reference to it arises 
from the fact that writers have not kept in view what constitutes a fever. 

Febrile action which has a local cause is not an essential fever, and should 
not be described as such. It happens that in children a symptomatic remit- 
tent fever arises from a variety of local causes, as dentition, intestinal worms, 
subacute gastro-intestinal inflammation, etc. But all such cases should be 
excluded from our consideration of remittent fever as clearly as we distin- 
guish the continued fever of pneumonia or bronchitis from that of typhus 
or typhoid. 

There is an essential remittent fever of children due to malaria. The 
same conditions which produce intermittent fever do, in a certain proportion 
of cases, produce a fever which does not intermit, but continues with more 
or less pronounced exacerbations a certain number of days, when it ceases or 
becomes intermittent. Those who practise in malarious localities notice a 
larger proportion of cases of remittent fever among children than adults, 
because their constitutions are less able to resist the malarial poison, so that 
an exposure which in an adult would produce milder disease — to wit, a tertian 
ague — frequently causes a quotidian or remittent in the child. 

In hot countries, where the malarial poison is more active and the diseases 
due to malaria more severe than in the temperate regions, cases of remittent 
fever due to the marsh miasm are more common than in the temperate 
regions. The "jungle fever 1 ' of India is a malarial remittent fever of a 
severe type. 

In my opinion, the term " remittent fever," if retained in nosology, should 
be restricted to those fevers of a remitting type which are due to marsh 
miasm, so that it differs from intermittent fever in the fact of a greater 
intensity and not in its essential nature. The one disease is characterized 
by intervals of apyrexia, and the other by periods of a diminution, but not 
cessation, of the febrile symptoms. 

In New York City, and probably in other localities in the temperate zone, 
a continued fever of a mild type not infrequently occurs in children, espe- 
cially in the spring and autumn, running a course of one to two, three, or 
even four, weeks, with in many cases a slight increase in the latter part of 
the day. Children with this fever are languid, moderately thirsty, and with- 
out appetite. They complain in the first days of headache. Their tongue is 



406 COXSTITUTIOXAL DISEASES. 

moderately furred. They have a slight cough, no diarrhoea, a temperature of 
101° or 102°, and many of them do not feel ill enough to go to bed, except 
at the usual hours of sleep, during the whole progress of the disease, which 
continues a variable time, from one to three weeks. This disease physicians 
of New York sometimes designate remittent, sometimes malarial, and occa- 
sionally, the severe cases, typho-malarial. I have noticed that this light 
form of fever occasionally occurs in a household or asylum in connection 
with typical cases of typhoid fever, and therefore am led to regard it as a 
mild form of this disease. Thus in a family in West Fifty-fourth street two 
children had this fever so mildly that they were every day dressed and sitting 
quietly in the room, but their aunt, a lady of about thirty years, who took 
care of them, sickened with a severe typical and protracted typhoid fever 
while she was attending them. In the Roman Catholic Orphan Asylum of 
this city typhoid fever occurred some years ago, and some of the cases were 
of the mild form described above, but two or three were fatal, and the 
characteristic lesions of typhoid fever were discovered at the autopsies. 
Therefore this mild continued fever, having perhaps a slight but scarcely 
appreciable morning remission, should not, in my opinion, be designated 
remittent, malarial, or typho-malarial— terms which have been applied to it — 
but be regarded as a mild typhoid fever. It seems to me that typhoid fever, 
like diphtheria, does sometimes present so mild a type in childhood that the 
patients are not confined to bed, and their sickness terminates in one or two 
weeks, instead of three or four, as stated in the books. 

Symptoms. — This disease begins with chilliness and headache, and exacer- 
bations and remissions occur each day. In severe cases the temperature 
during certain hours reaches 104° or 105°, and the exacerbation may be 
accompanied by delirium or stupor. The severe headache, restlessness, and 
jactitation show that the nervous system is profoundly involved in certain 
cases. There may be distinct remissions in the beginning, and afterward, for 
a few days, the fever be pretty uniform, when it again remits or ceases. The 
tongue is covered with a light fur. Thirst, loss of appetite, a tendency to 
constipation, and scanty, high-colored urine containing urates, are common 
symptoms. 

Diagnosis ; Prognosis. — Typhoid fever usually comes on more grad- 
ually than remittent fever, and is not attended by so great a daily variation 
in temperature. It is of more importance to make the differential diagnosis 
between remittent fever and the acute local diseases, especially meningitis 
and pneumonitis ; but a careful examination of the signs and symptoms, 
which will be considered hereafter in our remarks on the local diseases, will 
enable us to make the diagnosis. The prognosis is favorable with prompt 
and appropriate treatment. 

Treatment. — Prompt treatment by one of the salts of quinine is required. 
Formerly it was thought advisable to employ first laxative and diaphoretic 
remedies, in the belief that quinine, if administered immediately, might cause 
cerebral congestion. But since the bromides and antipyrine came into use, 
no treatment preparatory to the use of quinine is required, unless a single 
laxative dose in the beginning, as by calomel or the magnesium citrate. 
Alternate doses of quinine and bromide of potassium, at intervals of two 
hours, will in a few days control the fever. The bromide will prevent any 
ill effects of the quinine in producing cerebral congestion, which was formerly 
feared. In cases attended by marked pyrexia, jactitation, and delirium anti- 
pyrine should be added to the bromide. 



TYPHOID FEVER. 407 

CHAPTER III. 
TYPHOID FEVEE. 

Typhus and typhoid fevers occur in children, but the former is mild and 
infrequent, rarely occurring except when adults of the same household are 
affected. It requires little treatment besides good nursing. Typhoid fever, 
on the other hand, is not infrequent in children, and, as it presents certain 
peculiarities prior to the age of puberty, it is proper to describe it in this con- 
nection. This disease is much less common in infancy than in childhood, 
and in the first half of infancy is believed to be rare. Still, there can be no 
doubt that many cases in the first years of life are not diagnosticated, being 
mistaken for subacute and protracted entero-colitis. It is probably more 
common under the age of six years than is usually supposed, although the 
younger the child below this age the less frequent does it appear to be, while 
above the age of six years it is more and more frequent until puberty. In 
the statistics of Cadet de Gassicourt, embracing 276 children, 3 were at the 
age of two years, 7 at the age of three years, 8 at four years, 13 at five 
years, and the number gradually increased in successive years until there 
were 32, 41, and 42 cases at the ages of twelve, thirteen, and fourteen years. 
Farnham has reported a case occurring in a girl of three years whose father 
was at the time convalescing from the fever. She complained of feeling 
tired, and was listless, but fretful. Her surface was hot and face flushed in 
the latter part of the day. Her temperature on the seventh day reached 
104.8°, when she was put to bed. The fever ceased on the sixteenth day, 
after which the temperature was subnormal for ten days. 

Causation. — Klebs in 1881 announced that he had discovered a bacillus 
in cases of typhoid fever, which he believed to be the cause of the disease, 
and which he designated the bacillus typhosus. Each bacillus contained a 
spore in its interior, and often one at its extremity from which new bacilli 
developed. 1 About the same time Eberth also discovered the bacillus in the 
intestinal mucous membrane, the mesenteric glands, and spleen in typhoid 
fever, and ascertained that it differed from other bacteria in the staining. In 
17 cases these bacilli were found in 6, and not found in ll. 2 

Gaffky announced the results of his observations and experiments with 
the bacillus typhosus. He succeeded in cultivating it in various substances. 
Upon the surface of potato, sterilized by steam, it grows abundantly, forming 
rods 0.2,u thick and 0.6,u to 0.8/7. in length. The rods have active movement 
and are aerobic. 

The bacillus typhosus is constantly found at an early stage of typhoid 
fever in the spleen, mesenteric glands, Peyer's patches, and the solitary 
follicles. Occasionally it has been discovered in the lungs, liver, and kidneys, 
and rarely in the blood. When the symptoms pertaining to the fever begin 
to abate, the bacillus also begins to disappear, so that in the fourth week it 
sometimes cannot be discovered, and is usually less abundant than in the first 
and second weeks ; but it may be present after the fourth week. The bacilli 
occur in colonies or irregular masses. The figure represents the bacilli as 
observed in the spleen. 

The bacillus typhosus has not been discovered in any other disease than 
typhoid fever, although search has been made for it. Frankel and Simmonds 
inoculated rabbits with it. The animals were sick in consequence, and in 
those that died the spleen, the solitary follicles, Peyerian patches, and certain 

1 Phila. Med. Times, Dec. 3, 1881. 2 Brit. Med. Jour., Nov. 26, 1881. 



408 



CONSTITUTIONAL DISEASES. 



lymphatic glands were found tumefied. For the reasons stated, pathologists 
for the most part agree that this bacillus is the cause of typhoid fever, but 
from the fact that no bacilli, or but few, are found in the blood, it is not 

Fig. 57. 




Fig. 58. 



improbable that the fever and other prominent symptoms of the disease may 
be largely due to ptomaines which the bacilli produce. 

The bacillus typhosus is very tenacious of life. Prudden found that it 
could be cultivated after it had been frozen in ice one hundred and three 
days ; also after it had been subjected to a heat of 132.8°, and again when it 
had been alternately frozen and thawed. 1 Yidal and Chantemesse, by capil- 
lary punctures of the spleen during the life of the patient, obtained the 
bacillus, with which they inoculated mice and guinea-pigs, and subsequently 
discovered this organism in their lungs and abdominal organs. They also found 
it in the placenta of a typhoid patient who aborted at the fourth month. 2 

Yaughan and Novy obtained cultures of the typhoid bacillus from the 
water used by a considerable number of typhoid-fever patients, and the 

syrupy extract containing the bacillus and the 
ptomaines produced by it, injected under the skin 
of cats, caused 2° to 4.5° of rise in temperature. 
They have formulated the following definition of 
the disease : i- An infectious disease arises when a 
specific pathogenic micro-organism, having gained 
admittance to the body, and having found the con- 
ditions favorable, grows and multiplies, and in so 
doing elaborates a chemical poison which induces 
its characteristic effects." 3 

The discover}* of the bacillus typhosus and of 
its causal relation to typhoid fever affords import- 
ant aid to our knowledge of the manner in which 
typhoid fever is produced. The theory advocated 
by Murehison, that this disease may originate de 
novo by exposure to filthy accumulations of any 
kind, is now known to be false. Only such sub- 
stances can communicate the disease as contain 
the specific bacillus, and it is obviously necessary 
2 Lond. Lane, 1887. 3 Ptomaines and Leucomaines, 1888. 




Diagrammatic representation 
of Peyer's patches in typhoid 
fever : a, early stage* with 
swelling of the patch ; b, later 
stage with sloughing; c. ulcer 
with infiltrated walls (Thier- 
felder). 

1 iV r. Med, Rec, 1887. 



TYPHOID FEVER. 409 

that this bacillus should in some manner enter the system, so as to infect the 
individual. Exhalations from the most filthy accumulations, and even inocu- 
lation with the most fetid material, will not cause typhoid fever unless the 
bacillus typhosus be present. But the remarkable vitality of this organism, 
and its power of propagation in certain substances in common use, as water 
and milk, give rise to epidemics in localities where it happens to be introduced. 

Typhoid fever is seldom, and perhaps not at all, contracted by inhaling 
the breath of a patient or exhalations from his surface, but his urinary and 
fecal excreta contain the bacillus in abundance and are the most common 
source of infection. Many instances are on record of epidemics caused by 
the use of water for culinary or drinking purposes which had been in some 
manner polluted by the excreta of typhoid patients. One of the earliest 
recorded instances of this kind was observed by the late Prof. Austin Flint 
in 18-43. In a village in Western New York a traveller with typhoid fever 
was cared for at the inn, and his excreta were deposited near the well which 
supplied the whole village except one family. The stranger died, and within 
a month typhoid fever occurred in all the families of the village except the 
one that obtained water from a different well. At Pierrefonds 23 persons 
occupied adjacent houses. The water which they used was obtained from 
shallow wells into which it had percolated through a porous soil from a 
neighboring stream. This stream received the drainage of two cesspools, 
one being thirty and the other sixty-five feet from the well, and the well was 
on lower ground than the cesspools. In August and September, 20 of the 23 
persons were attacked with typhoid fever, and in one of the houses 4 died. 
The water supplying this house was examined by Chantemesse in October, 
and was found to contain the bacillus of typhoid fever in abundance. A 
month subsequently none could be found. Vienna, Angouleme, Cincinnati, 
and Bordeaux may be mentioned among the places where the occurrence of 
typhoid fever has been traced to pollution of the drinking-water. In 1888 a 
severe epidemic of typhoid fever occurred at Iron Mountain, Michigan, and 
in the drinking water employed in families that had suffered from the disease 
Vaughan and Novy found the typhoid bacillus. Therefore, sufficient obser- 
vations have been made to show that many epidemics of typhoid fever have 
been caused, and are still caused, by the use of polluted drinking water which 
contained the specific bacillus, and that when epidemics arise from this cause 
it apparently gains admittance into the system through the digestive appa- 
ratus. In 1871, Ballard, health officer of Islington, called attention to the 
fact that the use of infected milk sometimes causes typhoid fever. He had 
investigated an outbreak of the disease which was apparently produced by 
rinsing milk-cans with water which was polluted by direct communication of 
the tank with drains. Since then a considerable number of epidemics have 
been traced to the use of infected milk. The milk in most of the investigated 
cases was contaminated by polluted water employed in rinsing the cans or 
added to the milk for the purpose of diluting it. Milk may also receive 
the typhoid bacillus from ice which contains this organism and is employed 
for the purpose of reducing the temperature or for dilution. Seitz, Wolf- 
hiigel, and Reidel have shown that the typhoid bacillus grows freely in milk. 
Yaughan mixed water containing the typhoid bacillus with milk, and sub- 
sequently was able to obtain from the milk a poisonous extract due to the 
growth and activity of the bacillus (Med. News, Jan. 28, 1888). Therefore 
the milk-supply should also be investigated on the occurrence of an epidemic. 

But typhoid fever is probably communicated by the inhalation of air 
which contains the typhoid bacillus, although, as we have seen, the disease is 
not likely to be contracted by the attendants of typhoid patients if there be 
prompt and efficient disinfection of the excreta. In New York Cit} T many 



410 CONSTITUTIONAL DISEASES. 

observations show that the filthy flowing streams in the sewers are infected 
with the typhoid bacillus, and cases occur in which the fever seems to be 
due to the escape of the sewer gas into the houses. Thus, in my practice, 
in a house whose plumbing was supposed to be faultless three children who, 
so far as known, had not been exposed outside, sickened with typhoid fever. 
A thorough examination finally revealed the escape of sewer gas into the cel- 
lar in a strong current. The inference is that in such instances the tainted 
air conveys the bacillus to the lungs, and this organism enters the system 
through this organ. But it is true that the bacillus in such instances may be 
deposited from the air in the food or drink, or in the mouth or fauces, and be 
swallowed, so that the systemic infection may occur through the digestive 
system. But it suffices, so far as the employment of preventive measures is 
concerned, to know that an atmosphere infected by exhalations from filthy 
sources may communicate typhoid fever without the actual presence of a 
typhoid patient. Between 1873 and 1885 one hundred and forty -six cases of 
typhoid fever occurred in one of two barracks occupied by the German artil- 
lery, while cases did not occur in the other barrack, although the water and 
food used in the two were the same. Finally, suspicion fell upon the bed- 
linen and clothing, and the discovery was made that recent patients had worn 
the clothes of men previously attacked, and even stains of dried fecal matter 
were found in their pants. Saturation of the infected articles and the barrack 
with chlorine gas followed by dry heat was now employed, and no more cases 
occurred (Med. Press and Oirc, March 28, 1888). Therefore the typhoid 
bacillus gains admittance into the system not only by the use of infected 
drinking water, milk, and solid food, but also by the inhalation of an infected 
atmosphere. 

Anatomical Characters. — Since typhoid fever is a constitutional dis- 
ease, we would expect to find early and important changes in the blood. No 
alteration, however, has been discovered in this fluid peculiar to typhoid 
fever. The amount of fibrin is diminished, as in most of the essential fevers r 
and its coagulation is feeble, forming, when the blood stands, soft, small, and 
dark clots. When the fever has continued for some time a state of anaemia 
more or less decided supervenes in which the amount of albumen and blood- 
corpuscles is diminished. Although there are often decided symptoms refer- 
able to the nervous system, no constant changes have been discovered in the 
brain or spinal cord. The changes observed in them when death has occurred 
in the course of typhoid fever have been for the most part due to other 
causes. It is different with the respiratory system. After the first week of 
typhoid fever mild bronchitis is almost as constant as inflammation of the 
fauces in scarlet fever, and accordingly we find in fatal cases redness and 
thickening of the bronchial mucous membrane, which is covered with a viscid 
and ordinarily scanty secretion. Hypostatic congestion of the lungs, with 
more or less oedema, and in severe and enfeebled cases hypostatic pneumo- 
nia, are not uncommon. In the bronchitis and state of feebleness we have 
the causes of pulmonary collapse, and this lesion is not infrequent over 
limited portions of the lungs, especially if the bronchitis affect the smaller 
tubes. 

The lesions occurring in the digestive system are important. The pharynx 
is normal or slightly affected. The mucous membrane of the oesophagus 
and stomach is sometimes normal or nearly so, and in other cases hyperaemic. 
It is said that ulcers have been occasionally observed in the cardiac end of 
the oesophagus. The mucous membrane of the small intestine is more or 
less injected, and at an early period, even by the second or third day, the 
patches of Peyer, solitary glands, and at the same time the mesenteric, 
begin to enlarge. I have made microscopic examination of these glands in 



TYPHOID FEVER. 411 

typhoid fever of the adult, and have found a considerable increase of the 
small round granular cells of which they are composed. It appears, there- 
fore, that the enlargement is due mainly to hyperplasia of the cellular ele- 
ments of the glands, though there is probably infiltration to a certain extent 
of inflammatory products between the cells. The mucous membrane over 
the glands undergoes inflammatory thickening and softening. In the adult 
sloughing of this membrane is frequent, with the disintegration of the glands 
and their elimination into the intestines, producing ulcers, small and circular, 
corresponding with the site of the solitary glands, or large and oval or irreg- 
ular, corresponding with the site of Peyer's patches. Disintegration of these 
glands and the formation of ulcers are less frequent in children than in 
adults. In the adult who recovers the mesenteric glands and the solitary and 
agminate which are not destroyed return to their normal state by fatty degen- 
eration, liquefaction, and absorption of the redundant cells. In the child this 
is the common result, instead of sloughing and disintegration, as regards both 
the solitary and agminate glands, and the uniform result as regards the mesen- 
teric, and I may add bronchial glands, which are also in a state of hyperplasia. 
The absence of ulceration or its slight extent aiFords explanation of the fact 
that intestinal perforation is very rare in children. The inflammatory changes 
described above pertain chiefly to the ileum. The duodenum and jejunum 
present their normal appearance or are moderately hyperaemic in places and 
their follicles swollen. 

The spleen gradually enlarges, often to twice the normal size, has a dark- 
red color, and is softened. Enlargement of the spleen possesses great diag- 
nostic value in those cases in which the diagnosis is obscure. For while very 
similar intestinal lesions may occur in chronic entero-colitis, the coexistence 
of these lesions with the splenic enlargement and softening shows the con- 
stitutional nature of the malady. The liver usually presents its normal 
appearance, or it may be pale in consequence of the anaemia, or, on the other 
hand, it may be hyperaemic. Microscopic examination sometimes reveals a 
granular state of the hepatic cells with indistinct nuclei. 

In cases which are severe and which present a decidedly adynamic type 
the muscles become soft and flabby, the action of the heart is feeble, and 
more or less passive congestion of the viscera results. In such cases con- 
gestion of the kidneys and albuminuria are not infrequent. Parenchymatous 
degeneration of the kidneys occasionally occurs, the epithelium becoming 
granular, the cells indistinct, and their nuclei invisible. Liebermeister states 
that he has frequently noted the absence of albuminuria during the fever 
when the autopsy showed marked degenerative changes in the kidneys. 
Inflammation of the endocardium and pericardium is rare, but the myo- 
cardium exhibits structural changes in severe cases. Atrophy and fatty 
degeneration of its muscular fibres sometimes occur, which may lead to the 
formation of clots in the cavities of the heart, and consequent emboli in 
other organs. Hoffmann demonstrated the occurrence of fatty degeneration 
of the minute arteries in various organs in prolonged cases of typhoid fever, 
and degenerative changes have also been observed in the voluntary muscles. 

Pathology. — Recent investigations relating to the acute infectious dis- 
eases of childhood render it probable that as regards most, if not all, of them 
systemic infection occurs through ptomaines or poisonous chemical agents 
which are produced by the action of the microbes which are the specific 
principles. This is believed to be true as regards typhoid fever. In 1885, 
Brieger obtained a ptomaine from cultures of the typhoid bacillus which, 
inoculated in guinea-pigs, caused salivation, hurried breathing, dilated pupils. 
diarrhoea, paralysis, and death within one to two days. 1 From such observa- 
1 L. Brieger, Ueber Ptomaine, Berlin, 1885-86. 



412 CONSTITUTIONAL DISEASES. 

tions and experiments the theory has arisen that the symptoms which 
characterize typhoid fever are mainly due, not directly to the action of the 
bacillus, but to a ptomaine or ptomaines created by the bacillus and ab- 
sorbed into the system. This theory also receives support from the 
observations and experiments of Hoffa. Sirotirvin, Beaumer and Peiper, and 
others. 

Incubative Period. — As in scarlet fever and diphtheria, the incubative 
period in typhoid fever varies. In three cases detailed by Griesinger the 
fever began twenty-four hours after exposure. In a school at Clapham, 20 
out of 22 boys sickened, according to Murchison, within four days after 
exposure. Authenticated cases of a longer incubative period are on record, 
so that Murchison believed that it is commonly about two weeks, and 
William Budd that it is in most instances from ten to fourteen days, but 
cases have occurred in which it seemed to be as long as twenty-eight 
days. 1 

Symptoms. — Typhoid fever has a prodromic stage of a few days, some- 
times of a week or more, in which the child appears languid, indisposed to 
play, and has little appetite, but complains of no pain unless occasional 
slight headache, and has no symptoms which would lead the friends, or even 
physicians, to suspect the nature of the disease which impends. By and by 
a slight fever occurs. 

In exceptional cases typhoid fever begins with a chill, followed by 
pronounced fever. It occurred in 3 of the 14 cases observed by Dr. Jacobi 
in Bellevue Hospital. This was a larger proportion of cases with such com- 
mencement than I observed in the epidemic of 1882 or have since observed, 
but the cases in Bellevue seem to have been unusually severe, since 5 of the 
14 died. 

The fever, which gradually becomes more pronounced, remits, but does 
not cease in the morning, and it has evening exacerbations. After the first 
week of fever the remissions are less marked, but the fever is not uniform 
at any period in its course. Hence some of the writers on diseases of children 
continue to designate typhoid fever of children remittent fever, fully aware 
of its identity with typhoid fever of the adult. As the case advances the 
appetite fails, all solid food being refused, and liquid food being taken more 
from thirst than hunger. The tongue in the first week, and in some patients 
throughout the course of the disease, is covered with a light moist fur, while 
in others having a graver type of the fever the tongue after the first week is 
dry and brown. During the prodromic period and in the first week the 
bowels act regularly or are slightly relaxed, and they are readily affected by 
purgative medicines. After the first week there is in some children a tend- 
ency to diarrhoea, which requires now and then the use of astringents, the 
stools being watery and brown or dark yellow. Diarrhoea is less frequent in 
children than in adults, and in some children it does not occur during the 
entire sickness. The abdominal walls are seldom retracted, but prominent, 
especially after the first week, in consequenee of meteorism, which is present 
in children as well as adults. Sometimes there is apparent tenderness when 
pressure is made over the right iliac region, but this must not be confounded 
with hypersesthesia, which is common in the commencement of febrile diseases 
in children, and which is observed especially upon the abdomen, chest, and 
inner part of the thighs. 

The respiration in the first week is slightly accelerated, as it is in all 
febrile diseases. In the second week, and subsequently when bronchitis is 
developed, the respiration is ordinarily more accelerated, though not in a 

1 8ee article ''Typhoid Fever," American System of Practical Medicine, Philada., 
18S5, Lea Bros. 



TYPHOID FEVER. 413 

marked degree, unless in those exceptional instances in which there is an 
abundant collection of mucus in the smaller bronchial tubes. A cough is 
often present, dependent on the bronchitis, and varying in character accord- 
ing to the degree and stage of the inflammation. In the first days of the 
fever it is infrequent or lacking ; at a later stage it is more frequent and not 
so dry, though in cases of ordinary severity the amount of expectoration is 
inconsiderable. Hypostatic congestion, oedema, hypostatic pneumonia, spleni- 
zation or thickening of the alveolar walls, and collapse, which not infre- 
quently occur in the advanced disease, increase more or less the frequency of 
the respiration and the cough and modify the physical signs. 

The pulse in the first week, in ordinary cases, is from 100 to 110 or 115. 
It gradually becomes more accelerated, numbering in the second week 123 or 
more ; in grave cases even 160. The more frequent the pulse, the greater 
the danger and more unfavorable the prognosis. During the exacerbations 
the number of pulsations per minute is fifteen or twenty more than in the 
remissions. The change in temperature corresponds with that of the pulse, 
being from 1° to 2° higher in the exacerbation than remission. The ex- 
tremes of temperature in cases of ordinary severity are about 101° to 104°. 
A temperature above 105° shows a grave, perhaps a fatal, type of the disease 
or else a serious complication. 

There is great variation as regards the symptoms referable to the nervous 
system. Headache is common in the prodromic and initial stages, after which 
it ceases. A few are delirious even from an early period, screaming loudly 
or muttering incoherently, but the majority are quiet, having, indeed, a 
degree of mental dulness, but being able to appreciate questions when 
aroused and answering correctly. Subsultus tendinum and carphologia, 
which some exhibit, show that there is profound disturbance of the nervous 
system. Epistaxis occurs occasionally in the first week, as in the adult, but 
is usually slight. 

The rose-colored eruption appears in children as well as adults between 
the sixth and twelfth days, but is more frequently absent in the former than 
the latter ; sometimes the number of spots is less than half a dozen. Su- 
damina are common in the second and third weeks, and perspirations may 
occur at any time in the course of the fever, but without amelioration of 
symptoms. More or less deafness is common, being in most instances a 
purely nervous symptom, without, therefore, any structural change in the 
ear, but it is possible, as has been suggested by certain writers, that it some- 
times results from inflammatory thickening of the Eustachian tube or exter- 
nal meatus, or from a weakened and flabby state of the muscles of the 
ear. 

Duration. — As in diphtheria, so in typhoid fever, the duration varies 
greatly in different cases. Mild forms of the disease terminate within one 
week, but cases of a severe type may continue several weeks. Henoch 
states that the duration of 80 cases which he observed were as follows : 
from seven to ten days, 11 ; from ten to fifteen days, 26 ; from fifteen to 
twenty days, 16 ; from twenty to thirty days, 21 ; and from thirty to 
forty-nine days, 6 cases. The limits in the duration were therefore seven 
days in the shortest and mildest cases, and forty-nine days in those that were 
the most protracted. In the cases of short duration the diagnosis was ren- 
dered clear by the roseola, enlargement of the spleen, and diarrhoea. When 
the disease begins to abate, there is frequently in the morning a complete 
apyrexia, and a return of the fever in the latter part of the day. This period 
of an intermittent fever usually varies from two to five days. Forchheimer, 
who observed a severe epidemic of typhoid fever in Cincinnati, says that 
this disease in children sometimes terminates in six days (Columhus Med. 



414 CONSTITUTIONAL DISEASES. 

Jour.. 1888). In a discussion relating to typhoid fever at a recent session 
of the New York Medical Association. Dr. E. G. Janeway also stated that 
this disease sometimes terminates within ten clays. In cases continuing 
three or four weeks the patient becomes progressively more emaciated and 
feeble, and in a severe form of the disease his condition seems very unprom- 
ising to one not familiar with the clinical history of the fever. Pale, 
emaciated, and feeble, probably passing his evacuations in bed, and taking 
little notice of objects around him, he presents at the close of the third week 
or in the fourth an appearance of helplessness, notwithstanding the best 
nursing and the constant employment of sustaining measures, which is truly 
discouraging. 

Relapses — Second Attacks. — Rilliet and Barthez called attention to the fact 
that relapses sometimes occur, although they observed only 3 such cases in 
111 patients. Henoch witnessed 21 relapses in 137 cases, the relapses occur- 
ring after severe and after mild cases. The majority of the cases in which 
relapse occurred were, however, mild. As a rule, the relapse occurred between 
the third and fifth weeks, and after a complete apyrexia of three to ten days. 
In one case even eighteen days of apyrexia had occurred when the fever was 
renewed. In some cases the relapse took place during the decline of the fever, 
when there was a morning intermission and an evening fever, the fever again 
becoming continuous. Eichhorst. in examining the records of 6Q6 cases occur- 
ring in Zurich, ascertained that second attacks occurred in 28 persons, or in 
4.2 per cent, of the cases. He has observed cases of a third and even of a 
fourth attack, so that, as in diphtheria, a first or even a second attack does 
not destroy the susceptibility to the disease. 

Complications. — The chief complications of typhoid fever are broncho- 
pneumonia, already sufficiently described, enteritis, intestinal hemorrhage, 
peritonitis, otitis, parotiditis, and muguet. In one instance I lost a patient 
about ten years old. in whom the fever had nearly terminated, by the sudden 
accession of croup. There is, as we have seen, in ordinary cases more or less 
inflammation of the mucous membrane of the air-passages and of the intes- 
tines, especially in the vicinity of the patches of Peyer. It is easy to under- 
stand how, under circumstances which may arise in the fever favorable to the 
development of mucous inflammations, the bronchitis and enteritis may so 
increase as to constitute complications. They are the most frequent of the 
serious complications. 

Feeble action of the heart, common in severe cases of typhoid fever, and 
which after the second week is partly attributable to granulo-fatty degenera- 
tion of the muscular fibres of the heart, which is frequent in grave forms of 
the infectious diseases, obviously favors the occurrence of bronchial and pul- 
monary congestion. Hence the proneness in these cases of the inflammation 
to extend downward from the larger to the smaller bronchial tubes and to 
the lungs, so that broncho-pneumonia becomes an occasional very grave 
complication. 

In the child as well as adult with this disease the mucous membrane 
of the lower part of the ileum in the vicinity of Peyer's patches is fre- 
quently thickened and hyperaemic — a true intestinal catarrh. We can readily 
understand how under certain circumstances this may become aggravated so 
as to constitute an intestinal inflammation of considerable extent and gravity 
— a severe entero-colitis, so that the local symptoms predominate over the 
constitutional and aggravate the latter. 

In the adult, as is well known, the Peyerian and solitary glands, becom- 
ing more and more prominent by proliferation of the cellular elements (the 
lymphoid cells), begin to ulcerate in the second week, and slough in the third, 
forming the typhoid ulcer, which is slow in healing and aids in keeping up 



TYPHOID FEVER, 415 

the diarrliceal state. Such destructive or necrotic inflammation is rare in 
young children, but it may occur in those of a more advanced age. 

Intestinal hemorrhage is therefore an occasional accident. Hillier met 4 
cases in 30 of the fever. It indicates the presence of ulcers upon the surface 
of the intestines. The younger the child the less the liability to it. Some 
in whom it has occurred recover, but others die. A girl of nine years com- 
plained of severe abdominal pain on the seventeenth day of the fever, which 
was followed by syncope and death. At the autopsy one of Peyer's patches 
was found deeply ulcerated, and at the bottom of the ulcer was a perforation 
through which blood had escaped into the peritoneal cavity. 

Intestinal perforation is more rare in children than in adults, as might be 
inferred from the statement already made that intestinal ulceration is less 
frequent and extensive in them. Statistics show that perforation in children 
occurs only once in 232 cases. Therefore, as perforation is the common cause 
of peritonitis in this disease, this inflammation is a rare complication. Peri- 
tonitis may. however, occur in typhoid fever without perforation. In one 
such case (an adult) in the fever wards attached to Charity Hospital local 
peritonitis with fibrinous exudation occurred opposite two ulcerated patches 
of Peyer. the ulcers extending nearly to the peritoneum, but not perforating. 
The lesions observed in this case throw light on those cases of peritonitis 
complicating typhoid fever which recover, the cause of which has received 
a different explanation. 

In advanced and greatly debilitated cases thrush sometimes appears in 
the interior of the mouth and upon the fauces. It is always an unfavorable 
prognostic symptom in children suffering from chronic or protracted disease. 
Parotiditis is also a rare complication. Otitis, commencing with pain and pro- 
ducing a discharge which may continue for weeks, is not rare, though less 
frequent than in scarlet fever. The otitis is commonly external, but it may 
in scrofulous subjects extend to the middle ear. 

Diagnosis. — This is more difficult in children than in adults, and the 
younger the child the greater the difficulty. In infants protracted entero- 
colitis, with fever and a dry furred tongue, cannot in certain cases be posi- 
tively diagnosticated from typhoid fever by the symptoms and clinical history. 
Typhoid fever is believed, however, to be rare at this age, for an infant 
nourished at the breast is very seldom exposed to the cause of the disease. 
When, however, as now and then happens, a young child presents the symp- 
toms characteristic of protracted subacute entero-colitis or typhoid fever, and 
older members of the household have the fever, it is highly probable that the 
case is one of the latter disease, and it should be treated accordingly. 

Even in older children typhoid fever is frequently mistaken for simple 
subacute enteritis or entero-colitis, or vice versa. The following facts aid in 
the differential diagnosis : In typhoid fever there is a total loss of appetite, 
while in the subacute intestinal inflammation food is not entirely refused. 
Diarrhoea commences early in the inflammation, while in the fever it does not 
occur ordinarily till after the lapse of a few days. Abdominal tenderness in 
the fever is not appreciable or is located in the right iliac region ; in the other 
disease it is general over the abdomen or located in the umbilical region. 
In typhoid fever there is bronchitis with a cough, which is absent in the 
inflammation. In typhoid fever there are certain other symptoms, more 
or fewer of which are present in most cases, and which do not occur in the 
intestinal diseases, except as a coincidence ; for example, headache, epistaxis, 
stupor, delirium, and perhaps the rose-colored spots. The evening rise of 
temperature and enlargement of the spleen are also important diagnostic 
symptoms. When it is very important to make a positive diagnosis, cultures 
may be made from blood drawn from the spleen, from the sediment of albu- 



416 CONSTITUTIONAL DISEASES. 

minous urine, or from the feces, and if the disease be typhoid fever the 
specific bacillus will be found. 

Typhoid fever may be mistaken for meningitis during the first week, but 
in meningitis there is more constipation, irritability of stomach, and less ele- 
vation of temperature. Moreover, in meningitis at a comparatively early 
stage we are able to detect patches of congestion of the features coming and 
disappearing suddenly, and slight inequality of the pupils or their oscilla- 
tion when the light is uniform — signs which are lacking in typhoid fever. 
In a doubtful case the ophthalmoscope might be employed, which in menin- 
gitis discloses congestion of the vessels of the retina, oedenia, etc.— anatomi- 
cal changes which do not pertain to typhoid fever. 

The differential diagnosis of typhoid fever and acute tuberculosis may be 
made by attention to the following points : In tuberculosis there is cough, 
with some acceleration of respiration from the first, without epistaxis, stupor, 
or other nervous symptoms, and without the abdominal symptoms which are 
so prominent in the fever. The occurrence of typical cases in the same 
house or in those patients who have been similarly exposed has in certain 
instances enabled me to make a clear diagnosis. 

In localities where diseases due to marsh miasm occur, the remittent fever 
arising from this cause and typhoid fever bear considerable resemblance to 
each other. The two, indeed, may coexist — a fact observed during the late 
Civil War, so that cases in which this coexistence occurred were designated 
typho-malarial. In malarial remittent fever the commencement is more 
abrupt, the vomiting and headache more severe, and the remissions more 
marked than in typhoid fever. Moreover, quinine exerts a decided control- 
ling effect in the fever due to marsh miasm, while its effect in typhoid fever 
is much less pronounced. 

Prognosis. — A much larger percentage of children recover than of adults. 
Although there be great emaciation with loss of strength, recovery may be 
confidently predicted, provided that no serious complication occur. Grave 
symptoms, as high fever, delirium, severe diarrhoea, an unusually rapid and 
feeble pulse, have a bad import. If from any cause the system is in a 
marked degree debilitated when the fever begins, the prognosis is much less 
favorable than in those who are robust. Thus the presence of hereditary 
syphilis, of tuberculosis, of severe scrofula, or of bronchial or intestinal 
catarrh when typhoid fever begins, greatly increases the danger. But in 
fatal cases which I have met the unfavorable result occurred, as a rule, from 
the complications rather than directly from the malady. Of the compli- 
cations, the most serious are intestinal ulceration, giving rise to hemor- 
rhage or even perforation, and consequent peritonitis, diphtheria, pneu- 
monia, nephritis, pleuritis with serous or purulent effusion, meningitis, and 
granulo-fatty degeneration of the myocardium. Complications like these 
largely increase the mortality of typhoid fever. The condition in which 
severe typhoid fever leaves a patient is favorable for the development of 
tubercles, and now and then they occur, disappointing our expectations and 
prediction of recovery. The possibility of a relapse should be borne in 
mind, so that the patient should remain in bed, free from excitement and 
with plain but nutritious and easily digested diet, until convalescence is well 
advanced. 

Treatment. — Typhoid fever, like typhus, cannot be abridged by treat- 
ment, and the indication is to sustain the vital powers, diminish the intensity 
of the fever, and arrest if possible any untoward symptom or complication. 
Quinia, so useful in malarial diseases, may be administered in small doses 
for its tonic effect and as an aid in promoting digestion. It is commonly and 
properly prescribed in some convenient vehicle for this purpose, but it does 



TYPHOID FEVER. 417 

not antagonize the typhoid as it does the malarial poison. Perturbating 
medicines, and especially cathartics, should be given with caution. The 
tendency to intestinal ulceration and hemorrhage and the anaemic nature 
of the fever require abstinence from or cautious use of such agents. A 
temperature remaining under 103° usually involves little danger. If it 
remain above 103° morning and evening, antipyretic measures should be 
employed. I therefore order the nurse to bathe frequently the forehead, 
face, hands, arms, neck, and sometimes the chest, with cold water, to which 
it is proper to add alcohol or some spirituous lotion. A cloth wrung out of 
ice-water, or an ice-bag. should be applied over the head, and the hands may 
be allowed to lie a considerable time in a washbowl containing the lotion, 
which is always grateful to the patient. The water treatment thus applied 
will usually reduce the temperature one. two, or three degrees within a few 
hours. Cold general baths are not so well tolerated by children as by adults. 
Collapse has sometimes followed their use, and, on the other hand, benefit 
has apparently in some cases accrued from their employment when the tem- 
perature was above 104°. The bath, if used, should be at a temperature of 
about 88°, and the patient should not be immersed in it longer than five to 
eight minutes (Henoch). It seems preferable, however, in most cases of high 
temperature, to endeavor to reduce it by cold sponging or cold compresses. 
A compress frequently wrung out of ice-water or containing broken ice mixed 
with bran, or a rubber ice-bag applied over the head and another over the 
abdomen, or Leiter's coils applied over the same parts as the compress, grad- 
ually abstract the heat, and with more safety to the patient than the use of 
the cold bath. Ice applications should be discontinued if the temperature 
fall to 103° or if the patient complain of chilliness. Even an afternoon tem- 
perature of 104° does not require ice applications or any active antipyretic, 
provided there is a decided morning remission. Moderate doses of quinine 
and general sustaining remedies suffice for such cases. 

Of the internal antipyretics, sodium salicylate, antipyrine, phenacetin, 
acetanilide, and quinine have been chiefly employed. The sodium salicylate 
is likely to retard digestion, and it sometimes causes albuminuria. Its use, 
therefore, cannot be recommended. Antipyrine effectually reduces the tem- 
perature, but is depressing. It may be given, especially in the early stages 
of typhoid fever, in doses of two to five grains according to the age, along 
with an alcoholic stimulant, with a good result. Some physicians recommend 
the use of phenacetin instead of antipyrine, as being equally effectual and 
less depressing. It may be given in about half the dose of antipyrine. Ace- 
tanilide in one-fourth the dose of antipyrine also reduces the fever, but it is 
also depressing, and it does not, so far as I am aware, possess any advantages 
over antipyrine. In- the majority of cases the reduction of temperature is 
best effected by cold-water bathing or cold compresses and the internal use 
of quinine. Quinine in moderate doses as a tonic appears to be useful during 
the entire course of the fever, but in cases of a temperature dangerously 
high antipyrine, acetanilide, or phenacetin is now preferred by good observers 
to the use of large doses of quinine, which were formerly employed (Von 
Ziemssen). 

The fact that in a large proportion of cases the typhoid bacillus enters 
the system in the ingesta, and effects a lodgement upon the gastro-intestinal 
surface, suggests the query whether the early use of antiseptics administered 
by the mouth might not be destructive to the bacillus, and thus in a measure 
destroy the cause of the disease. The remedy which has thus far been used 
for this purpose, and which is supposed by some to exert a specific action 
upon the disease, apart from its purgative or eliminative effect, is calomel. 
Its mode of action is not fully understood. It is supposed by some to be in 
27 



418 CONSTITUTIONAL DISEASES. 

part changed into the bichloride in the stomach and intestines. Von Ziems- 
sen in treating adults administers early in the attack three 7 i -grain doses 
of calomel at intervals of two hours, and obtains by so doing a considerable 
reduction of temperature during the following twelve hours. Liebermeister 
claims that the use of calomel diminishes the intensity of the disease, and 
Wunderlich even believed at one time that it might abort the fever. On the 
other hand, Weil, Griesinger, and Baumler assert, from their observations and 
statistics, that the mortality is not diminished nor is the number of aborted 
cases increased by the use of calomel, and that it is only useful as a mild, 
non-irritating evacuant. Wilson says : " Attempts to fix the hypothetical 
specific action by long-continued calomel treatment, and to force a true abor- 
tive calomel treatment, have at different times failed, as has also the subli- 
mate treatment of typhoid fever." The use of calomel should probably be 
restricted to one or a few doses at the commencement of the attack. 

Since it is impossible to arrest typhoid fever or abridge its duration by 
any therapeutic measures of which we are cognizant, the indication is to 
sustain the vital powers and alleviate, so far as possible, the symptoms. 
Quinine is not only employed in large doses to reduce the fever, but it is 
often prescribed in small doses during the subsequent progress of the disease, 
in the belief that it may exert some tonic effect. It does not appear, how- 
ever, to exert any marked controlling effect upon the symptoms. Iodine, 
iodide of potassium, and carbolic acid have also been employed internally, 
but their efficacy is doubtful ; but Liebermeister states that the iodide of 
potassium employed in two hundred cases, although it did not appreciably 
ameliorate the symptoms, apparently diminished the mortality. 

The mineral acids have also their advocates, and statistics appear to show 
benefit from their use. The late Prof. Austin Flint treated 78 patients with 
the acids with a death-rate of 10.25 per cent, and 70 patients without the 
acids with a death-rate of 20 per cent., the treatment otherwise of the two 
classes being alike. The mineral acid which, in my opinion, is most useful is 
the muriatic, since it aids digestion, which is greatly impaired by the fever, 
and since the digestive ferments in this disease are apparently secreted in 
insufficient quantity. I usually prescribe this acid with pepsin, as in the 
following formula : 

R. Pepsini puri, in lamellis, gj ; 
Acidi muriat. dilut., ^ij ; 

Syr. simplic, ^j ; 

Aquae, ^iij. — Misce. 

Give one teaspoonful in water every two hours to a child of ten years. 

The wine of pepsin of the National Formulary may also be employed, but 
each teaspoonful contains only about one minim of the dilute muriatic acid, 
so that the quantity of the acid might be increased. 

In all but the mildest cases alcoholic stimulants are required, especially 
after the first week. In the first week they may be withheld in ordinary 
cases, but in attacks of a severe type and attended by early prostration they 
may be required at or soon after the commencement of the fever. The indi- 
cations for their use are feeble pulse with faint systolic sound and marked 
nervous symptoms, as subsultus tendinum, stupor, and delirium. In the 
prostration consequent on high fever and protracted and obstinate diarrhoea 
the use of alcohol is important as a cardiac stimulant. Still, such large and 
frequent doses of the alcoholic compounds are not needed as are useful in 
diphtheria. The object in employing them is to sustain the flagging pulse 
and promote digestion and assimilation. The preferable mode of employing 
alcoholic stimulants rs in the form of milk punch or wine whey. 



TYPHOID FEVER. 419 

Wakefulness, which is sometimes an unpleasant symptom, and which may 
occur with, and is perhaps largely due to, the headache, may be relieved by 
a powder of phenacetin and bromide of potassium or sodium, two to five 
grains of the former and double or treble its amount of the bromide. The 
new remedy, sulphonal, triturated and given in sweetened water or milk, 
will also relieve the insomnia, and in some instances it appears to be prefer- 
able to the other agents which have been employed for the purpose of procur- 
ing sleep. An opiate, as Dover's powder, is also useful in relieving wakeful- 
ness, and should be prescribed if the patient at the same time have diarrhoea. 
Three grains may be given to a child of eight years. For headache, whether 
accompanied by wakefulness or not, I know no better remedy than phenacetin 
in combination with the bromide of potassium or sodium, as given above. At 
the same time, cool lotions should be applied to the head. The same remedies 
which are appropriate for the insomnia are also useful for the delirium which 
occasionally occurs in cases of a grave type. The constant application of cold 
to the head and an increase in the stimulation may also be required. 

AVe have stated elsewhere that diarrhoea is less common in the typhoid 
fever of children than in that of adults, but it sometimes occurs, and should 
be promptly checked. The subnitrate of bismuth in rather large and fre- 
quent doses, along with an opiate and vegetable astringent, will usually con- 
trol the diarrhoea, and the same remedies should be employed in intestinal 
hemorrhage. Recently in my practice in the case of a boy of about fifteen 
years near the close of the second week of typhoid fever, so large a flow 
of blood occurred from the intestines that the condition of the patient was 
very critical. But the loss of blood was quickly checked by large doses 
of subnitrate of bismuth and teaspoonful doses of equal parts of the cam- 
phorated tincture of opium and tincture of catechu, and the patient recovered. 
The constipation which is sometimes present in typhoid fever, and more fre- 
quently in children than in adults, may be relieved by an enema of water, 
half a pint containing one or two teaspoonfuls of glycerin. 

The distention of the stomach and intestines with flatus is sometimes so 
great that it requires treatment. It may cause a sensation of fulness and 
prevent the descent of the diaphragm in respiration, and it increases the 
danger of perforation if a deep intestinal ulcer exist. External pressure 
and manipulation should not be employed under such circumstances, since 
they might cause rupture, nor should the hypodermic needle be used. Jacobi 
has witnessed a fatal peritonitis produced by the escape of fecal matter 
through the punctures caused by the needle (Arch, of Pediatrics, Dec, 1888). 
The proper remedy for the flatus is either turpentine or the aniseed cordial 
of the National Formulary. 

Sustaining measures are of the highest importance. Typhoid fever ceases 
after some days or weeks with or without medicinal treatment, and the patient 
recovers if the strength be adequately supported. Hence the food should be 
sufficient in quantity, of the most nutritious kind, and easily digested and 
assimilated. It must be liquid, since the repugnance to food and the mental 
state of the patient render it impossible to feed him with solids unless in the 
mildest cases. Milk sterilized by heat or peptonized, the meat broths, and 
gruels with milk must be the food chiefly employed. Since the digestive fer- 
ments are apparently secreted in small quantity during the fever and diges- 
tion is feebly performed, it is well to employ predigested food when the dis- 
ease is unusually severe and the temperature very high. Peptonized milk 
and the beef peptones of the shops are useful under such circumstances. 
Milk with some farinaceous food long boiled, as barley flour, should in most 
instances be employed as the principal article of diet. The mistake is some- 
times made by anxious friends of giving the nutriment too frequently, even 



420 CONSTITUTIONAL DISEASES. 

every half hour. As in health, so in this disease, the digestive function 
requires intervals of rest, so that, as a rule, the food should not be given 
oftener than every two hours, and then in sufficient quantity. A dose of 
pepsin before each feeding, employed in the formula recommended above, 
has been useful in critical cases in my practice. So important is the diet in 
typhoid fever that the physician neglects an important duty if he do not give 
as full and explicit directions in regard to the feeding as he does in refer- 
ence to the use of medicines. The room occupied by the patient should be 
large and well ventilated. Statistics show that the result is far better if there 
be a plentiful supply of pure fresh air than in closed and ill-ventilated apart- 
ments ; so that in some of the hospitals patients are treated in canvas tents 
upon the hospital grounds when the weather is suitable. Nearly forty years 
ago an emigrant-ship arrived at Perth Amboy, N. J., with more than 300 
passengers, 82 of whom were sick with fever, and several had died at sea. 
There being no hospital in the town, the fever patients, 12 of whom were 
insensible, were placed in hastily-constructed wooden shanties with sail roofs. 
To add to their discomfort, a violent thunder-storm occurred which drenched 
the interior of the shanties, and yet with simple medicinal treatment and the 
use of buttermilk and animal broths only 1 of the 82 patients died. Four 
sailors who sickened with the fever after the arrival of the vessel were taken 
to a dwelling-house, and two of them died. These facts, which were related 
to the New York Academy of Medicine at the June meeting in 1853 by the 
late Dr. John H. Griscom, and were published in the Transactions of the 
Academy for that year, strongly impressed the profession of New York with 
the importance of fresh air in the treatment of typhus and typhoid fevers, 
and the knowledge thus obtained has no doubt been instrumental in saving 
many lives. But in the treatment of children the sudden reduction of tem- 
perature and currents of cold air should be avoided, for by taking cold the 
bronchial catarrh which is ordinarily present in a mild form might be aggra- 
vated, or a croup or pneumonia might be developed. 

Von Ziemssen states that in severe cases attended by feeble heart-action 
the patient should not be allowed to move without assistance or get out of 
bed, for sudden heart-failure and death " frequently result from a neglect of 
this rule " {Annual of Med. Sci., vol. i., 1888). The occurrence of bed-sores 
should be guarded against by change of position and the use of a soft mat- 
tress or water-bag. In severe cases attended by much prostration the patient 
should not be allowed to leave the bed until some days after the fever has 
ceased and the strength is in a measure restored. 

Prophylaxis. — The duty of the physician does not cease with the care of 
the patient. He should employ efficient measures to prevent the propaga- 
tion of the disease. Especial attention should be given to the disinfection 
of the excreta. This may be accomplished by adding six ounces of chloride 
of lime to one gallon of water, and mixing one quart of this solution with 
each fecal evacuation and a less quantity with each urinary discharge. Crude 
carbolic acid (one part to ten or fifteen of water), sulphate of copper (one 
part to twenty of water), or, best of all, corrosive sublimate (one part to two 
hundred to four hundred of water) may be employed for the same purpose. 
The disinfected discharge should be allowed to stand a few moments before 
it is emptied into the water-closet, and the closet should be thoroughly 
flushed out. In country practice great care must be taken that the dis- 
charges be not emptied in such a place that they can by any possibility 
percolate into the well which supplies the drinking-water to the families or 
neighbors. ^ A pound or more of corrosive sublimate in solution should be 
sprinkled in the vault, and chloride of lime should be dusted over the con- 
tents. The milk used in the family should be sterilized by steaming two 






CEREBROSPINAL FEVER. 421 

hours at a temperature of 180° to 190°, or by boiling, and the drinking- 
water should be boiled or distilled. Care should be taken to disinfect 
promptly the clothing worn by the patient and the bedding. This may be 
accomplished b} T placing them immediately when removed in boiling water 
or bv immersing them in a solution of corrosive sublimate (one part to one 
thousand), or carbolic acid (one part to fifty), or sulphate of copper or 
chloride of lime (one part to one hundred). 



CHAPTER IV. 

CEREBROSPINAL FEVER. 

Definition. — Probably a microbic disease. It is manifested chiefly by 
the occurrence of cerebro-spinal meningitis. Its prominent symptoms are 
such as meningitis gives rise to — to wit, fever, headache, tonic contraction 
of the muscles of the nucha, hyperaesthesia, and neuralgic pains in the trunk 
and extremities. It is non-contagious, or contagious in a very low degree, 
and, as with most of the microbic diseases, its victims are chiefly the young. 
It is ordinarily a primary disease, but it sometimes occurs as a complication 
of other acute as well as chronic maladies. It begins abruptly or without a 
premonitory stage, and it is often speedily fatal from the intense hyperemia 
of the nervous centres or the severity of the cerebro-spinal meningitis. In 
other cases, after weeks or months of suffering and progressive loss of flesh 
and strength, death occurs in a state of extreme prostration. In those who 
recover convalescence is protracted and slow. 

This disease has been designated by different terms in different countries, 
as spotted fever, cerebro-spinal fever, malignant purpuric fever, typhus 
petechialis, typhus syncopalis, and febris nigra, expressive of its constitu- 
tional nature. Those who employ such terms regard it as a general or 
systemic disease, with the meningitis as its local manifestation, just as 
pharyngitis is a local manifestation of scarlet fever or bronchitis of measles 
or pertussis. This opinion of its nature receives strong support from the 
clinical fact that in severe forms of the disease extravasations of blood occur 
early under the skin, indicating a profoundly altered state of the blood and 
systemic infection. The disease has also been designated by terms expressive 
of its local nature, as epidemic meningitis, epidemic cerebro-spinal menin- 
gitis, typhoid meningitis, malignant meningitis. We will treat hereafter of 
the nature of this malady, and endeavor to justify the opinion which has led 
to the use of terms that indicate its constitutional character. 

History. — Whether cerebro-spinal fever occurred previously to the pres- 
ent century is uncertain. If it did it was confounded with other diseases. 
Vieussens in 1805 was apparently the first who wrote a clear and unmistak- 
able description of it, designating it " a malignant non-contagious fever." He 
described an epidemic of it which appeared in Geneva, Switzerland, in a 
family of 3 children, of whom 2 died in twenty-four hours. Two weeks 
later -1 children in another family died of it, after an illness of less than a 
day, and a young man in another house died with similar symptoms after an 
equally brief illness, his surface having a deeply congested or violet appear- 
ance. In these and subsequent cases the attack began in the latter part of 
the day or at night, and was attended by vomiting, violent headache, con- 
vulsions, dysphagia, petechia, and tonic contraction of the posterior muscles 



422 CONSTITUTIONAL DISEASES. 

of the neck and trunk, producing retraction of the head and opisthotonos. 
Thirty-three lost their lives during this epidemic, after a sickness varying 
from twelve hours to five days. Within the next two years epidemics of 
cerebro-spinal fever occurred in Bavaria, Holland, Germany, and at about the 
same time or soon after in parts of England. 

The first American cases of the disease, so far as is now known, were at 
Medfield, Massachusetts, in 1806. From 1806 to 1816 occasional outbreaks 
of it occurred in England, France, and America in several localities. It 
appeared in both Canada and the United States. From 1816 to 1828, so far 
as is now known, only two epidemics of it occurred, and they were limited 
to small areas and were of brief duration. The one was at Middletown, Con- 
necticut, and the other at Vesoul, France. In 1828 it occurred in Trumbull 
county, Ohio, in 1830 at Sunderland, England, and in 1833 at Naples. After 
the Naples epidemic a respite from the disease appears to have occurred, in 
both the Eastern and Western Hemispheres, until 1837. In that year it 
appeared in the south of France, in and around Bayonne, and gradually 
extended to isolated localities over almost the whole of France. It occurred 
at this time among troops in their barracks as well as civilians, and in some 
localities, of the troops affected from 50 to 75 per cent. died. Even Versailles 
and Paris did not escape. During the twelve years from 1837 to 1849, 
France suffered far more than any other country from this disease. It was 
especially common and fatal among the soldiers in many localities, and at 
some of the military stations in France several successive epidemics occurred. 
In the decade from 1839 to 1849 cerebro-spinal fever extended to Naples, 
the Komagna, Sicily, Gibraltar, Algeria, and various places in Denmark, 
England, and Ireland. 

In 1842 the United States was again visited by cerebro-spinal fever in 
localities at a distance from the seaboard, and therefore, apparently, not by 
communication from Europe. In 1842-43 it occurred in Kentucky, Tennes- 
see, Alabama, Illinois, Mississippi, and Arkansas. From 1840 to 1850 it 
visited Montgomery in Alabama, Beaver county in Pennsylvania, Cayuga 
county in New York, and New Orleans in Louisiana. Between 1850 and 
1854 there is no record of its occurrence in either hemisphere, but from 
1854 to 1860 it ravaged the Scandinavian peninsula and caused more than 
four thousand deaths. 

Since 1860 certain localities in nearly every civilized country have been 
severely visited by this disease. In all these countries it is justly regarded 
as one of the most fatal and important of the epidemic maladies. 

An interesting fact in regard to these many epidemics on both continents, 
which have been reported by competent observers, is that they have occurred 
in isolated localities far apart and without the least evidence of transporta- 
tion. Cerebro-spinal fever has not, so far as I am aware, in any instance 
extended from one locality to an adjacent one in the manner of contagious 
diseases. The cause of the malady has evidently arisen or been created in 
the places where the cases have occurred, and is not susceptible of transpor- 
tation so as to produce the disease elsewhere. Cerebro-spinal fever resembles 
in this respect the diseases due to marsh miasm. 

But since 1860 this disease has appeared in this country in another phase. 
It has become or is being established — or. to use the phrase commonly em- 
ployed in medical literature, naturalized — in the cities of the United States. 
For some years not a week has passed without the report of deaths from this 
cause in New York, Philadelphia, Jersey City, and Chicago. It is probably 
already permanently established in Cincinnati, St, Louis, Minneapolis, Newark, 
and San Francisco, since deaths from it have been reported in these cities 
during many consecutive weeks. 



CEREBROSPINAL FEVER. 423 

In Xew York City prior to 1866 only 4 deaths occurred from what was 
perhaps cerebro-spinal fever, since in 1838, 2 deaths were reported from so- 
called spotted fever. 1 in 1850 and 1 in 1861. What was the nature of this 
spotted fever is now a matter of conjecture. In 1866, 18 patients died of 
cerebro-spinal fever within the city limits, and not a year has passed since, 
and in the last few years not a week, without deaths from it. From 1866 to 
1872 the annual deaths from this disease in New York varied from 18 to 48. 
Commencing in December, 1871. and continuing during the first half of 1872, 
a severe epidemic occurred, producing a large mortality. Many who recovered 
permanently lost their hearing and some their sight from the attack. In this 
epidemic the physicians of New York were fully aroused to the importance 
of the disease which was causing so much suffering, and which attacked the 
lower animals, especially the jaded horses of the city car- and stage-lines, not 
a few of them dropping down in harness, so suddenly did the attacks occur. 
In 1872, 782 deaths, chiefly of children, resulted from cerebro-spinal fever 
within the city limits. This epidemic appeared to produce a greater dissemi- 
nation of the disease and more firmly established it in the city, for since then 
the annual deaths from it have varied between 97 in 1878 and 461 in 1881. 
In Philadelphia cerebro-spinal fever began in 1863, causing 49 deaths in that 
year, and it has never been absent from that city since. Prof. Stille states 
that between 1863 and 1882 it has caused 2049 deaths within the city limits. 
In Philadelphia, as in New York, it has for some years produced a nearly 
uniform weekly mortality. The prevalence of cerebro-spinal fever in the 
United States and its probable importance in the future may be inferred from 
the fact that it has recently occurred also in Cincinnati, Minneapolis, Denver, 
Norfolk, Boston, Worcester, New Haven, Albany, Syracuse, Auburn, Mil- 
waukee, Wilmington, Detroit, Baltimore, Charleston, Toledo, Mobile, Salt 
Lake, Grand Rapids, Providence, Chattanooga, Hartford, New Orleans, Fall 
Biver, Bichniond, Knoxville, and Nashville. 

Etiology. — That this disease is produced by a micro-organism is generally 
believed. Dr. A. Frankel and other European microscopists have carefully 
examined the bacteria found in the blood and tissues of those affected by it. 
At a meeting of the Berlin Medical Society, held February 12, 1883, Herr 
Leyden showed under the microscope specimens of micrococci found in a 
case of cerebro-spinal fever. They had an oval shape, were mostly in pairs, 
and were faintly tremulous. They resembled those found in pneumonia 
and erysipelas, but Leyden did not think them identical. At the same 
meeting Herr Baginsky related cases which seemed to show that in some 
instances the cause of cerebro-spinal fever and that of pneumonia might be 
identical. 1 

Dr. Y. 0. Pushkareff, connected with one of the barrack- infirmaries of 
St. Petersburg, states that in five cases of croupous pneumonia in which 
cerebro-spinal meningitis occurred as a complication he discovered in the pus 
taken from the cerebral meninges swarms of micrococci whose appearance 
under the microscope seemed identical with that of Friedlander's pneumococ- 
cus. They were either isolated or in groups of two, seldom in four, having 
distinct capsules, and they were absent from the fluid taken from the men- 
inges in simple pneumonia. Pushkareff" was able to cultivate the micrococ- 
cus taken from the meningeal pus, and the cultivated microbes, like their 
parents, presented an appearance identical with that of the pneumococcus. 2 
Moreover, Eberth, in a case of meningitis following pneumonia, believes that 
he found the same micrococcus in the lungs and in the liquid exuded from 
the inflamed pia mater. Frankel also states that he obtained from the puru- 

1 Deutsch. med. Wochenschr., April 4, 1883. 
2 Ejen.klin. Gazeta, April 21, 1885. 



424 CONSTITUTIONAL DISEASES. 

lent exudation in the pia mater, in a case of meningitis occurring with pneu- 
monia, a microbe resembling that in the pneumonic exudation. 1 

From the investigations of so many competent microscopists, therefore, 
it appears that the microbe found in the exudate of the meninges in cerebro- 
spinal fever, and which is supposed to sustain a causal relation to this dis- 
ease, bears a close resemblance in form to the pneumococcus, if it be not 
identical with it. But we would infer, from the fact that croupous pneu- 
monia is so universal a disease occurring in localities where there is no 
cerebro-spinal fever, that the cause of the two must be different, or, if there 
be a form of croupous pneumonia which is produced by the same microbe as 
that of cerebro-spinal fever, the pneumonia which is universal must have a 
different origin. The microbic causation of cerebro-spinal fever needs 
further investigation, which it will doubtless receive, before positive state- 
ments can be made. 

Among the conditions which are favorable for the occurrence of cerebro- 
spinal fever, and may therefore be regarded as predisposing to it, we may 
mention the winter season. Statistics collected in Europe and the United 
States show that while 166 epidemics occurred in the six months commencing 
with December, only 50 were in the remaining six months of the year. Ac- 
cording to the statistics of Prof. Hirsch, which were collected mainly from 
Central Europe, 57 epidemics were in winter or in winter and spring, 11 in 
spring, 5 between spring and autumn, 4 commenced in autumn and extended 
into winter or into winter and the ensuing spring, and 6 lasted the entire 
year. I suspect that the opinion expressed by Prof. Hirsch is correct, that 
the excess of epidemics in the winter months is due mainly to the greater 
crowding and less ventilation in the domiciles during the cold than during 
the warm months, especially among European peasantry. In New York 
City, where the state of the domiciles is about the same the year round, 
the season appears to exert little influence on the prevalence of the 
disease. 

The fact has repeatedly been observed that antihygienic conditions in- 
crease the liability to cerebro-spinal fever. Soldiers in barracks and the poor 
in tenement-houses suffer most severely when the epidemic is prevailing. In 
New York City the fact is often remarked that multiple cases occur for the 
most part where obvious insanitary conditions exist, as in apartments which 
are unusually crowded and filthy or in tenement-houses around which refuse 
matter has collected or which have defective drainage. The interesting chart 
prepared under the direction of Dr. Moreau Morris for the Health Board 
shows that comparatively few cases occurred in the epidemic of 1872 in those 
portions of the city where the sanitary conditions were good. Antihygienic 
conditions probably predispose to cerebro-spinal fever in the same way that 
they do to other grave epidemic disease, as, for example, to Asiatic cholera, 
whose ravages are chiefly where hygienic requirements are most neglected. 
We will presently relate striking examples which show how foul air increases 
the number and malignancy of cases. Insanitary conditions not only ener- 
vate the system and render it more liable to contract any prevailing dis- 
ease, but probably promote the development and activity of the specific 
principle. 

Is Cerebro-Spinal Fever Contagious ? 

It is the almost unanimous opinion of those who are most competent to 
judge from their observations that it is either not contagious or is contagious 
in a very slight degree. It is certain that the vast majority of cases occur 
1 Deutsch. med. Wochenschr., Nov. 13, 1886. 



CEREBROSPINAL FEVER. 425 

without the possibility of personal communication. Thus, in the commence- 
ment of an epidemic the first patients are affected here and there at a dis- 
tance from each other, often miles apart, and throughout an epidemic usually 
only one is seized in a family. Children may be around the bedside of the 
patient, passing in and out of the room without restriction, and yet we can 
confidently predict that none of them will contract the malady if there be 
proper ventilation and cleanliness and none of the conditions of insalubrity 
exist within or around the domicile. Moreover, when multiple cases occur 
in a family the disease begins at such irregular intervals in the different 
patients that there can be little doubt in most instances that it is not com- 
municated from one to the other, but, like the fevers from marsh miasm, is 
produced by exposure to the same morbific cause, existing outside the indi- 
viduals, but within or around the premises. Thus, in the Brown family 
treated by the late Dr. John Gr. Sewell x of New York, the first child sick- 
ened January 30th, and subsequently the remaining five children at intervals 
respectively of five, seven, eleven, twenty-five, and forty-five days. That so 
many were affected in one family was attributed by the doctor to the filthy 
state of the house and the bad plumbing, which allowed the free escape of 
sewer-gas. In my own practice, in the family which suffered the most 
severely of all, four patients were seized in succession, and yet I could see 
no evidence of contagiousness. The family occupied a small plot of ground, 
not more than thirty feet by one hundred, and their occupation was to pre- 
pare for the meat-market what is known as head-cheese. They lived on the 
second floor of the two-story wooden house in which the work was carried 
on. At the time of the sickness the shop contained four hundred heads of 
animals from which the meat for the cheese was obtained, and it was evident 
that decaying animal matter was present. The occupation and surroundings 
of this family afforded sufficient explanation of the fact that so many were 
attacked. Two workmen contracted the disease within about one week of 
each other, and were removed from the house. On January 26th, four 
weeks after the commencement of the malady in the workman who was first 
attacked, one child sickened with it, and died on February 1st. Fifteen 
days subsequently (February 16th) a second child was attacked, and, after 
a tedious sickness, finally recovered. The long and irregular intervals 
between these cases indicate that the disease was not contracted by one 
from the other. The important factor in causing so severe an outbreak of 
cerebro-spinal fever in this family was probably the miasm produced by such 
an occupation in the house where the family resided, with neglect of ventila- 
tion and cleanliness. 

But the strongest evidence that cerebro-spinal fever is either noncon- 
tagious or very feebly contagious is afforded by the fact that a large majority 
of the cases occur singly in families, although there is no isolation of the 
patients. The following are the statistics relating to this point in the cases 
which I have observed since cerebro-spinal fever commenced in New York, 
in 1871 : Single cases occurred in seventy families ; dual cases occurred in 
nine families ; three cases occurred in one family, and four cases in one 
family. Intercourse with the sick-room was unrestricted in all these fami- 
lies, so that children frequently went out and in, and sometimes assisted in 
the nursing. 

The most striking example of apparent contagiousness which has come 
to my knowledge was related by Hirsch, and is quoted by Yon Ziemssen. 
A young man sickened with cerebro-spinal fever on February 8th. The 
woman who nursed him returned to her home in a neighboring village, and 
there died of the same disease on February 26th. To her funeral mourners 
1 Medical Record, July, 1872. 



426 CONSTITUTIONAL DISEASES. 

came from a neighboring township, and after their return home three of them 
died with the same disease — one within twenty-four hours, another on March 
4th, and a third on the 7th. 

In one instance only in my practice did the facts point to contagiousness. 
A boy of twelve years died of cerebro-spinal fever, and was buried on Satur- 
day or Sunday. On Monday the mother washed the linen and bedclothes of 
the boy, which had accumulated and were in a very filthy state. Two days 
subsequently she was attacked, and her infant soon afterward, both perishing. 
The state of the bedding and apartments in this house, as seen by myself, 
was such as would be likely to concentrate and intensify the poison, render- 
ing it peculiarly active, for they were very dirty, and the mother, exhausted 
by her long and incessant watching and lack of sleep, and depressed by grief, 
rendered her system more liable to the disease by her self-imposed duties on 
the day after the funeral. One in her state of mind and body, standing for 
a considerable part of a day over the bedclothes and bedding of her child 
soiled by the excreta, would certainly be in a condition to contract the disease 
if it were contagious in any, even in the lowest, degree. In the present state 
of our knowledge, therefore, upon this important subject the evidence leads 
us to believe that with proper ventilation and cleanliness and the suppression 
of antihygienic conditions in an infected domicile those who are in a good 
state of body and mind will not contract the disease, but in the opposite con- 
ditions it is not improbable that the poison may be so intensified, and the sys- 
tem rendered so liable to receive the prevailing malady through impairment 
of the general health and diminished resisting power, that cerebro-spinal 
fever may, though rarely, be communicated either by the breath of the patient 
or by exhalations from his surface or from soiled clothing. 

The occurrence of cerebro-spinal fever in certain of the lower animals is 
a very interesting fact, especially as the question is sometimes asked whether 
it may not be communicated from them to man. In the epidemic of 1811 in 
Vermont, according to Dr. Gallop, even the foxes seemed to be affected, so 
that they were killed in numbers near the dwellings of the inhabitants. 
Cerebro-spinal fever, previously unknown in New York City, began, as stated 
above, in 1871, among the horses in the large stables of the city car- and 
stage-lines, disabling many and proving very fatal, while among the people 
the epidemic did not properly commence till January, 1872, although a few 
isolated cases occurred in December of 1871. No evidence exists, so far as 
I am aware, that the disease was in any instance communicated by these 
animals to man. Those who had charge of the infected horses, as the veter- 
inary surgeons, and stable-men, did not contract the malady, certainly not 
more frequently than others who were not so exposed. Although we may 
admit slight contagiousness, there has probably been no well-established 
example of the transmission of cerebro-spinal fever from animals to man. 
If transmission ever does occur, it is so rare that practically no account need 
be made of it. 

In some instances we are able to discover an exciting cause. An indi- 
vidual whose system is affected by the epidemic influence may perhaps escape 
by a quiet and regular mode of life, but if there be any unusual excitement 
or if the normal functional activity of the system be seriously disturbed, an 
outbreak of the malady may occur. Among the exciting causes we may 
mention overwork and lack of sleep, fatigue, mental excitement, depressing 
emotions, prolonged abstinence from food followed by over-eating, and the 
use of indigestible and improper food. Thus, in one instance among my 
cases a delicate young woman, at the head of one of the departments in a 
well-known Broadway store, was anxious and excited and her energies over- 
taxed at the annual reopening. Within a day or two subsequently the disease 



CEREBROSPINAL FEVER. 427 

began. Another patient, a boy. was seized after a day of unusual excitement 
and exposure, having in the mean time bathed in the Hudson when the 
weather was quite cool. Those children have seemed to me especially liable 
to be attacked who were subjected to the severe discipline of the public 
schools, returning home fatigued and hungry, and eating heartily at a late 
hour. In one instance which I observed a school-girl ten years of age 
returned from school excited and crying because she had failed in her exam- 
ination and had not been promoted. In the evening, after she had closely 
studied her lessons, the fever began with violent headache. 

Dr. Frothingham x writes as follows of the brigade in which cerebro-spinal 
fever occurred in the Army of the Potomac : " Under General Butterfield, a 
stern disciplinarian, .... the men were drilled to the full extent of their 
powers, often to exhaustion. I did not at the time recognize this as the 
cause of the disease in question, but I learnt that in the present epidemic in 
Pennsylvania the attack generally follows unusual exertion and exposure to 
cold.'' 

Many observers have noticed that bodily fatigue and mental depression 
and excitement are important factors in causing an attack of cerebro-spinal 
fever when this disease is epidemic. Dr. Gallop, in his history of cerebro- 
spinal fever as it occurred during the war of 1812, directs attention to the 
severity of the cases among the troops under General Dearborn, who were 
fatigued by marches and greatly dispirited on account of a repulse which 
they had sustained from the British. In one case which occurred in my 
practice a boy, six years and eleven months of age, was punished at school 
and came home with cheeks flushed from excitement, the excitement con- 
tinuing during the ensuing night. On the following day cerebro-spinal fever 
began with vomiting and chilliness, the attack ending fatally on the seven- 
teenth day. In another case, which was related to me by the mother and 
the physician, the patient, a bright girl twelve years of age, of nervous tem- 
perament and forward in her studies, had been much excited in competing 
for a prize in athletic exercises. In the evening of the same day a violent 
thunder-storm occurred, and after a severe clap she started from bed pallid 
and excited, and expressed the belief that she had been struck by lightning. 
The disease began immediately after this, and terminated fatally on the fifth 
day. 

Secondary Cerebro- Spinal Fever. 

Fagge 2 says : " Several observers have found that during or just after an 
epidemic of cerebro-spinal fever, meningitis has presented itself with unusual 
frequency as a complication of other acute diseases." He mentions croupous 
pneumonia, pleurisy, acute tonsillitis, and scarlatinal nephritis as the diseases 
upon which it is very liable thus to supervene. In this respect cerebro-spinal 
fever resembles diphtheria and erysipelas, which we know are very liable to 
occur in those who are suffering from other diseases. 

A striking example of cerebro-spinal fever occurring as a complication 
was recently seen by me in consultation. A child of about ten years with 
typical typhoid fever had reached about the twelfth day of a mild form of 
the disease. The initial headache had ceased, there was no delirium, the 
temperature was but moderately elevated, and no doubt had arisen in the 
mind of the experienced physician in attendance that the disease, which 
presented the characteristic signs, would terminate favorably after the usual 
time. Suddenly violent headache occurred, the temperature rose to 103° or 
104° F.,and in a few days fatal coma terminated the case. Another disease 

1 American Medical Times, April 30, 1864. 2 Practice of Medicine, vol. i. p. 614. 



428 



CONSTITUTIONAL DISEASES. 



in which I have seen cerebro-spinal fever occur as a complication is gastro- 
intestinal catarrh. 

Sex. — It is stated by certain writers that more males are affected than 
females. The statistics of hospitals and camps show this, for men subject 
to lives of hardship are especially liable to be attacked ; but in family prac- 
tice, in which a large proportion of the patients 1 are children, the number of 
males and females is about equal. Thus, in 105 cases occurring chiefly in 
my practice, but a few of them in the practice of two other physicians of 
this city. I find that 59 were males and 46 females : 91 of these were children. 
In New York City, during the epidemic of 1872, 905 cases of cerebro-spinal 
fever were reported to the Board of Health between January 1 and Novem- 
ber 1, and of these 484 were males and 421 females. Dr. Sanderson's 
statistics of the epidemic in the provinces around the Vistula, the cases 
being chiefly children, give also but a slight excess of males. Probably, 
therefore, in the same conditions and occupations of life the sexes are equally 
liable to contract this malady, and the excess of males in the above statistics 
is due to the fact that they lead a more irregular life and are more subject 
to privations and exposures. That soldiers on duty in barracks have been 
attacked while families in the vicinity escape, thus increasing the proportion 
of male cases, probably occurs in consequence of irregularities, hardships, 
and perhaps the lack of sanitary regulations in their mode of life. 

Age. — My observations lead me to think that the younger the patient 
the more frequently is cerebro-spinal fever overlooked and some other disease 
diagnosticated. Nevertheless, all published statistics, so far as I am able to 
ascertain, show that a large proportion of cases occur under the age of five 
years, and that a larger proportion of fatal cases are in the first year of life 
than in any other year. Thus, in New York City the ages of those who died 
from this disease in 1883 were as follows: 



Under 1 year 57 

From 1 to 2 vears 31 

From 2 to 3 " " 22 

From 3 to 4 " 12 

From 4 to 5 " 9 

From 5 to 10 " 37 

From 10 to 15 " 18 

From 15 to 20 " 15 



From 20 to 25 vears 7 

From 25 to 30 " 3 

From 30 to 35 " 4 

From 35 to 40 " 3 

From 40 to 45 " 1 

From 45 to 50 " 2 

From 50 to 60 " 1 

Over 60 vears 1 



The following are the statistics of the New York Health Board relating to 
the ages of the cases during the epidemic of 1872 : 



Under 1 year . 125 

From 1 to 5 vears 336 

From 5 to 10 " " 204 

From 10 to 15 " 106 



From 15 to 20 vears 54 

From 20 to 30 " " 79 

Over 30 years 71 

Total 975 



In the cases which occurred in my own practice, and in a few cases in the 
practice of other physicians added to mine, I find that the ages were as 
follows : 



Under 1 year 16 

From 1 to 3 vears 27 

From 3to 5 " 25 

From 5 to 10 " 20 



From 10 to 15 years 10 

Over 15 years 15 

Total 113 



In my practice, therefore, three-fourths of the cases have been under the 
age of ten years ; and the statistics of epidemics in other localities correspond 



CEREBROSPINAL FEVER. 429 

with mine in giving a large excess of cases in childhood. Thus, Dr. Sander- 
son, in examining the records of deaths in one epidemic, ascertained that 218 
had perished under the age of fourteen years, and only 17 above that age ; 
and although this does not show the exact ratio of children to adults in 
the entire number of cases, it is evident that the children were greatly in 
excess. 

The more advanced the age after the tenth year, the less the liability to 
this malady, so that very few who have passed the thirty-fifth year are 
attacked, and old age possesses nearly an immunity. In New York City, in 
which, as we have seen, cerebro-spinal fever has been occurring since 1871, 
only two cases have come to my knowledge which had passed the fortieth 
year. The age of one was forty-seven, and of the other sixty-three years. 
But nearly every year the statistics of the Health Board show that one or 
two old persons have died of this disease. 

Not a few cases occur in this city in infants of the age of three or four 
months. An infant of four months died of cerebro-spinal fever in the New 
York Infant Asylum, the nature of the disease not being known until it was 
revealed by the autopsy. 

Symptoms. — During the prevalence of cerebro-spinal fever cases now and 
then occur in which the symptoms are mild and transient and the health is 
soon fully restored. It seems proper to regard some, at least, of these as gen- 
uine but aborted forms of the disease. The following cases which occurred 
in my practice may be cited as examples : 

A boy eight years of age, previously well, was *taken with headache and 
vomiting, attended by moderate fever, on April 2, 1872. The evacuations 
were regular, and no local cause of the attack could be discovered. On the 
following day the symptoms continued, except the vomiting, but he seemed 
somewhat better. On April 4th the fever was more pronounced, and in the 
afternoon he was drowsy and had a slight convulsion. The forward move- 
ment of the head was apparently somewhat restrained. On the 6th the 
symptoms had begun to abate, and in about one week from the commence- 
ment of the attack his health was fully restored. 

A boy aged six was well till the second week in May, 1872, when he 
became feverish and complained of headache. At my first visit, on May 
14th, he still had headache, with a pulse of 112. The pupils were sensitive 
to light, but the right pupil was larger than the left. The bromide and 
iodide of potassium were prescribed, with moderate counter-irritation behind 
the ears. The headache and fever in a few days abated, the equality of the 
pupils was restored, and within a little more than one week from the com- 
mencement of the disease he fully recovered. 

These cases occurred when the epidemic of 1872 was at its height ; but 
if the symptoms are so mild and the duration of the disease short as in these 
two cases, the diagnosis must sometimes be doubtful. Observers in different 
epidemics report similar cases, and as the symptoms, so far as they appeared 
in my patients, seemed characteristic, I have not hesitated to regard them as 
genuine, but aborted cases. On such patients the epidemic influence acts so 
feebly, or their ability to resist it is so great, that they escape with a short 
and trivial ailment. 

Occasionally also during the progress of an epidemic we meet patients 
who present more or fewer of the characteristic symptoms, but in so mild a 
form that they are never seriously sick and never entirely lose their appetite. 
but the disease, instead of aborting, continues about the usual time. 

Thus, on January 4, 1873, I was called to a girl aged thirteen who had 
been seized with headache, followed by vomiting, in the last week in Decem- 
ber. During a period of six to eight weeks, or till nearly March 1st. she had 



430 CONSTITUTIONAL DISEASES. 

the following symptoms : Daily paroxysmal headache, often most severe in 
the forenoon ; neuralgic pain in the left hypochondrium, and sometimes in 
the epigastric region ; pulse and temperature sometimes nearly normal, and at 
other times accelerated and elevated, both with daily variations ; inequality 
of the pupils, the right being larger than the left during a portion of the 
sickness. The patient was never so ill as to keep the bed, usually sitting 
quietly during the day in a chair or reclining on a lounge, and she never 
fully lost her appetite. Quinine had no appreciable effect on the fever or 
paroxysms of pain. 

There can, in my opinion, be little doubt that this girl was affected by 
the epidemic, but so mildly that there was, for a considerable time, much 
uncertainty in the diagnosis. 

Cases like these, in which the disease is so feebly developed that the 
patient is never seriously sick, though unimportant pathologically, must be 
recognized in a treatise on cerebro-spinal fever. 

Mode of Commencement. — Cerebro-spinal fever rarely begins in the fore- 
noon after a night of quiet and sound sleep. In the cases which I observed 
in the severe and fatal epidemic of 1872, and in the 36 cases of which I have 
records observed since 1872, the commencement was almost without exception 
between midday and midnight. The fact that this disease does not commence 
after the repose of night till several hours of the day have passed shows the 
propriety and need of enjoining a quiet and regular mode of life, free from 
excitement and with sufficient hours of sleep, during the time in which the 
epidemic is prevailing. 

The commencement is usually without premonitory stage and sudden — 
unlike, therefore, the beginning of other forms of meningitis, which come on 
gradually, and are preceded by symptoms which, if rightly interpreted, direct 
attention to the cerebro-spinal system. Exceptionally certain premonitions 
occur for a few hours or days before the advent of the disease, such as lan- 
guor, chilliness, etc. Mild cases usually begin more gradually than cases 
of a severe type. The ordinary mode of commencement is as follows : 
The patient is seized with vomiting, headache, and perhaps a chill or chilli- 
ness, so that there is a sudden change from perfect health to a state 
of serious sickness. Rigor or chilliness is a common initial symptom, 
especially in adult patients. One patient, an adult female, had three or 
four chills of considerable severity in the commencement of the attack. Chil- 
dren often have clonic convulsions- in place of the chill, or immediately after 
it, partial or general, slight or severe. Stupor more or less profound, or, less 
frequently, delirium, succeeds. In the gravest cases semi-coma occurs within 
the first few hours, in which patients are with difficulty aroused, or profound 
coma, which, in spite of prompt and appropriate treatment, is speedily fatal. 
Those thus stricken down by the violent onset of the disease, if aroused to 
consciousness, complain of severe headache, with or without or alternating 
with equally severe neuralgic pains in some part of the trunk or in one of the 
extremities. The pain frequently shifts from one part to another. Among 
the early symptoms of cerebro-spinal fever are those which pertain to the eye. 
The pupils are dilated or less frequently contracted, and they respond feebly 
or not at all to light if the attack be severe or dangerous ; often they oscillate, 
and occasionally one is larger than the other. Vomiting with little apparent 
nausea, and often projectile, is common in the commencement of cerebro-spinal 
fever. It occurred as an early symptom in 51 of 56 cases observed by Dr. 
Sanderson. In 98 cases occurring in New York, most of them observed by 
myself, but a few of them related to me by the late Dr. John G. Sewall, 
vomiting occurred as an early symptom in 68 cases. Its absence on the first 
day was recorded in only 3 cases, while in the remaining 27 patients the 



CEBEBEO-SPINAL FEVER. 431 

records of the first day make no mention of its presence or absence. It was 
probably present in most of these 27 cases as one of the first symptoms. 

Since the epidemic of 1872. in examining patients, now numbering thirty- 
six, as has been already stated, I have made careful inquiry in regard to the 
mode of commencement, and with only two or three exceptions either the 
previous health had been good, or, if symptoms of ill-health antedated the 
cerebro-spinal fever, they were due to some ailment entirely distinct from 
this disease. In a boy four and a half years of age, living in Broadway, it 
was stated to me that the cerebro-spinal fever came on gradually with pains 
in the head and elsewhere : this case was mild throughout and the patient 
was never in imminent danger. In nearly all the cases, if the patients were 
at home and under observation, the exact moment of the beginning of the 
disease could be stated. Thus, a man aged twenty-eight returned from his 
work at midday, April 23, 1883, in good health and cheerful, ate a hearty 
meal at twelve M., and at one P. M. had a chill, with intense headache and 
severe vomiting. Minute red points appeared on his face after vomiting, 
from capillary extravasations. In this case the interesting fact was observed 
of a cessation of the symptoms, so that on the 24th and 25th, being free from 
pain, he went to Brooklyn. On the 26th, however, the symptoms returned. 
He had pains in the head, back, and extremities, and was seriously sick. 
Occasional remissions, so that very grave symptoms become mild for a time 
and then return in full severity, as well as distinct intermissions, as in this 
case, have been frequently noticed by observers in different epidemics. A 
little girl, previously entirely well, was slightly punished on June 11, 1882; 
immediately she vomited and seemed quite sick ; by kind nursing on the part 
of the mother she became better, so that on the 12th she had some appetite 
and went out. On the 13th cerebro-spinal fever began, with a temperature 
of 103° F., and its course was tedious. A robust girl, aged thirteen, vivacious 
and cheerful, went as usual in the morning to one of the public schools entirely 
well. Before the school was dismissed she returned home crying on account 
of dizziness and violent pain in the top of her head, in her knees, and in the 
calves of the legs. The case was attended by Prof. Alonzo Clark, Prof. Knapp, 
and myself, and was fatal after four and a half weeks. A boy aged ten returned 
from another public school in a similar manner, having gone to it in the morn- 
ing in apparently perfect health. 

We may therefore summarize as follows the symptoms which commonly 
attend the commencement of cerebro-spinal fever : Violent pain in some part 
of the head, and sometimes also in the trunk or limbs, vomiting, a chill or 
chilliness, clonic convulsions, dizziness, dilated, sluggish, or altered pupils, 
fever of greater or less intensity according to the severity of the attack, heat 
of head, and in most patients heat of the surface generally. If the disease 
be of a severe and dangerous type, these symptoms are frequently followed 
within a few hours by delirium, semi-coma, or coma. 

Nervous System. — Since in cerebro-spinal fever extensive and severe 
inflammation of the cerebral and spinal meninges occurs, with more or less 
congestion of the brain and spinal cord— lesions which we will consider here- 
after — we should expect that this disease would be attended by severe and 
dangerous symptoms, inasmuch as the cerebro-spinal axis exerts such a con- 
trolling influence upon the functions of the body. Also we should expect 
that the symptoms would vary according to the portion of the meninges 
which happens to be most severely inflamed. There is, indeed, variation in 
symptoms according to the extent and intensity of the meningitis and the 
degree in which the cerebro-spinal axis is congested or implicated, but cer- 
tain symptoms occur in all or nearly all cases, and as they are characteristic 
they render diagnosis easy. 



432 CONSTITUTIONAL DISEASES. 






Pain, already described as an initial symptom, continues during the acute 
period of the malady. It is ordinarily severe, eliciting moans from the 
sufferer, but its intensity varies in different patients. Its most frequent seat 
is the head, and the location of the cephalalgia varies in different patients 
and in the same patient at different times. One refers it to the top of the 
head, another to the occiput, and another to the frontal region, and the same 
patient at different times may complain of all these parts. The pain is 
described as sharp, lancinating, or boring. It is also common in the neck, 
especially in the nucha, the epigastrium, the umbilical and lumbar regions, 
along the spine (rachialgia), and in the extremities, where it shifts from one 
part to another. It is more common and persistent in the head and along 
the spine than elsewhere. The patient, if old enough to speak and not 
delirious or too stupid, often exclaims, " Oh my head ! " from the intensity 
of his suffering, but after some moments complains equally of pain in some 
other part, while perhaps the headache has ceased or is milder. In a few 
instances the headache is absent or is slight and transient, while the pain is 
severe elsewhere. After some days the pain begins to abate, and by the close 
of the second week is much less pronounced than previously. Vertigo occurs 
with the headache, so that the patient reels in attempting to stand or walk. 
I have stated above that vertigo may be a prominent initial symptom, as in 
the girl of thirteen years who suddenly became sick in the public school 
which she was attending, and reached her home with difficulty on account 
of the headache and dizziness. Contributing to the unsteadiness of the mus- 
cular movements is a notable loss of flesh and strength, which occurs early 
and increases. 

The state of the patient's mind is interesting. It is well expressed in ordi- 
nary cases by the term apathy or indifference, and between this mental state 
and coma on the one hand and acute delirium on the other there is every 
grade of mental disturbance. Some patients seem totally unconscious of the 
words or presence of those around them, when it subsequently appears that 
they understood what was said or done. Delirium is not infrequent, especially 
in the older children and in adults. Its form is various, most frequently quiet 
or passive, but occasionally maniacal, so that forcible restraint is required. 
It sometimes resembles intoxication or hysteria, or it may appear as a simple 
delusion in regard to certain subjects. Thus, one of my patients, a boy of 
five years, appeared for the most part rational, protruding his tongue when 
requested, and ordinarily answering questions correctly ; but he constantly 
mistook his mother — who was always at his bedside — for another person. 
Severe active delirium is commonly preceded by intense headache. In favor- 
able cases the delirium is usually short, but in the unfavorable it often con- 
tinues with little abatement till coma supervenes. 

On account of the pain and the disordered state of the mind patients 
seldom remain quiet in bed, unless they are comatose or the disease be mild 
or so far advanced that muscular movements are difficult from weakness. In 
severe cases they are ordinarily quiet for a few moments, as if slumbering, 
and then, aroused by the pain, they roll or toss from one part of the bed to 
another. One of my patients, a boy of five years, repeatedly made the entire 
circuit of the bed during the spells of restlessness. In mild cases or cases 
attended by less headache or mental disturbance patients are quiet, usually 
with their eyes closed unless when disturbed. 

Hyperesthesia of the surface is another common symptom. Few patients, 
not comatose, are free from it during the first weeks, and it materially increases 
the suffering. Friction upon the surface, and even slight pressure with the 
fingers upon certain parts, extort cries. Gently separating the eyelids for the 
purpose of inspecting the eyes, and moving the limbs or changing the position 



CEREBRO-SPIXAL FEVER, 433 

of the head, evidently increase the suffering and are resisted. I have some- 
times heard such expressions of suffering from slowly introducing the ther- 
mometer into the rectum that I was led to believe that the anal and perhaps 
rectal surfaces were hypersensitive. The hyperesthesia has diagnostic value, 
for there is no disease with which cerebro-spinal fever is likely to be con- 
founded in which it is so great. It is due to the spinal meningitis, and is 
appreciable even in a state of semi-coma. The headache and hyperesthesia 
fluctuate greatly in the course of the disease, and the former sometimes recurs 
at times, especially from mental excitement or from an afflux of blood to the 
brain from physical exertion, for months after the health is otherwise fully 
restored. 

Some contraction of certain muscles or groups of muscles is present in 
all typical cases. In a small proportion of patients it is absent or is not a 
prominent symptom — to wit, in those in whom the encephalon is mainly 
involved, the spinal cord and meninges being but slightly affected or not at 
all. This contraction is most marked in the muscles of the nucha, causing 
retraction of the head, but it is also common in the posterior muscles of the 
trunk, causing opisthotonos, and in less degree in those of the abdomen and 
lower extremities, and hence the flexed position of the thighs and legs, in 
which patients obtain most relief. The muscular contraction in not an initial 
symptom. I have ordinarily first observed it about the close of the second 
day, but sometimes as early as the close of the first day, and in other instances 
not till the close of the third day. Attempts to overcome the rigidity, as by 
bringing forward the head, are very painful and cause the patient to resist. 
In young children having a mild form of the fever, with little retraction of 
the head, the rigidity is sometimes not easily detected. I have been able in 
such cases to satisfy myself and the friends of its presence by placing the 
child in an upright position, as on the lap of the mother, and observing the 
difficulty with which the head is brought forward on presenting to the patient 
a tumblerful of cold water, which is craved on account of the thirst. The 
usual position of the patient in bed in a typical or marked case is with the 
head thrown back, the thighs and legs flexed, with or without forward arch- 
ing of the spine. The muscular contraction and rigidity continue from three 
to five weeks, more or less, and abate gradually ; occasionally they continue 
much longer. Through the kindness of Dr. Henry Griswold I was allowed 
to see an infant of seven months in the tenth week of the disease. It was 
still very fretful, and exhibited decided prominence of the anterior fontanel, 
probably from intracranial serous effusion, and marked rigidity of the muscles 
of the nucha, with retraction of the head. 

Paralysis is another occasional symptom, but complete paralysis of any 
muscle or group of muscles is less frequent than one would suppose from 
the nature of the malady. It may occur early, but is sometimes a late 
symptom. It may be limited to one or two of the limbs, as the legs or an 
arm and a leg, or it may be more general. In a case occurring in Roosevelt 
Hospital and published in the New York Medical Record for October 10. 
1878, the patient, a boy of ten years, was unable to move his legs one hour 
after the commencement of the disease. This sudden development of para- 
plegia in the commencement of cerebro-spinal fever resembled that of infan- 
tile paralysis, and was probably due to the same cause — to wit. active inflam- 
matory congestion of the anterior cornu of the spinal column. The sudden 
and complete loss of speech which occurs in certain cases, when consciousness 
is retained and the vocal organs are in their normal state, seems to be due to 
the fact that the portion of the brain which controls the function of speech 
is acutely congested or is the seat of effusion. Thus, in June, 1S82. a girl 
of three years whom I attended lost her speech on the second day of cerebro- 

.23 



434 



CONSTITUTIONAL DISEASES. 



spinal fever, and she was unable to articulate even the simplest word for two 
and a half months. Finally, she began to utter slowly and with difficulty 
the easiest monosyllables ; and after the lapse of more than a year her speech 
was slow and lisping, her hands were tremulous and unsteady, she was easily 
fatigued, and cried often from oversensitiveness. During the long period of 
speechlessness she daily made efforts to talk, but without uttering a sound. 
Strabismus, to which we will allude hereafter in treating of the eye, is a com- 
mon symptom, either transient or protracted, due to paralysis of certain of 
the motor muscles of the eye. 

Paralysis of more or fewer muscles has been noticed and recorded by 
many observers in this country and in Europe. Dr. Law observed a patient 
in the epidemic of 1865 in Dublin who could move neither arms nor legs, 
and Wunderlich saw one who had paralysis of both lower extremities and 
of a considerable part of the trunk. As this symptom is due to the inflam- 
matory process of the cerebro-spinal axis, it usually disappears in a few weeks 
as the inflammation abates and absorption of the inflammatory products 
occurs ; but it may be more protracted. In Wunderlich's case there was 
only partial recovery from the paralysis after the lapse of five months. 

Clonic convulsions have already been alluded to among the early symp- 
toms of the attack. They indicate a grave form of the disease, and are 

Fig. 59. 




not infrequent in young children, in whom they appear to occur in place 
of the chill which is common in those of a more advanced age. The 
eclamptic attack may be short and not repeated, or it may be protracted, or 
return again and again when the medicines which control it are suspended. 
Under such circumstances it is likely to end in profound coma, and is, of 
course, a symptom of great gravity. Thus, an infant of seven months had 
unilateral eclamptic attacks daily during the first week of the fever. The 
mother informed me that the convulsions seldom lasted longer than three 
minutes, and that the intervals between them were short. The child recov- 
ered with loss of sight from the cerebro-spinal fever, but still after the lapse 
of a year, when I examined him. he had symptoms which were apparently due 
to hydrocephalus. Another infant of eleven months had clonic convulsions 
nearly constantly during the first twenty-four hours, but with occasional 
brief intermissions. On the following day he was in profound coma and 
apparently dying, with a temperature of 105° F. To my astonishment, he 
gradually emerged from the state of unconsciousness, and after a week was 
able to sit in his cradle long enough to take drinks. 



CEREBROSPINAL FEVER. 435 

Occasionally eclampsia does not occur in the first days, but in the second 
or third week, when it is usually accompanied by an increase of other symp- 
toms, due to a recrudescence of the disease. A female infant aged eleven 
months, treated by me in 1882, had been sick one week when, during an 
increase in the febrile movement, she had one eclamptic seizure. Her recov- 
ery, though slow, was complete. A boy aged eleven and a half years, whose 
attack began with a chill, violent headache, and fever, and whom I visited 
frequently, died on the fourth day. Clonic convulsions did not occur in his 
case until within twenty-four hours of his death, when he had six seizures, 
which ended in coma. 

Though adult patients are much less liable to eclampsia than children, 
they are not entirely exempt. A male patient aged twenty-eight years,' 
whom I saw in consultation, had a single clonic convulsion lasting ten to 
fifteen minutes on the third day of his illness. In five weeks he had fully 
recovered, except that his headache returned upon any excitement. Even 
drinking a cup of beer caused it. Clonic convulsions are, however, much 
less common than the tonic muscular contraction and rigidity already alluded 
to. The latter occur to a greater or less extent in nearly all cases, and are 
symptoms of diagnostic value, the rigidity often extending to the muscles 
of the extremities. Thus, in a child aged three years who had no eclampsia 
the tonic contraction of the muscles of the extremities did not relax till after 
the twelfth day. 

Choreic or choreiform movements are occasionally observed. I do not 
refer to the tremulousness which sometimes occurs from weakness or as a 
premonition of eclampsia, but to a movement which has the character of 
true chorea. An infant aged ten months began to have choreic movements 
during the acute stage of the disease, most marked in the upper extremities 
and ceasing in sleep. They continued during the remainder of the life of the 
child, death occurring ten months subsequently from diphtheria. Rarely a 
choreiform movement of the eyes is also observed — a lateral movement from 
right to left and from left to right, designated nystagmus. I recollect two 
such cases. 

Drowsiness, already spoken of, is a common symptom, and it exists in all 
grades from slight stupor to profound coma. In some patients it is present 
from the first hour, while in others it occurs after a period of restlessness or 
delirium or it alternates with it. Stupor more or less profound is common 
after the attack of eclampsia or the chill. That it is a frequent symptom in 
severe cases receives ready explanation from the state of the brain and its 
meninges, for the exudation which occurs upon the surface of the brain and 
the serous effusion within the ventricles are sufficient to cause it by compress- 
ing the cerebral substance. It is surprising in some cases how profound the 
stupor may be — a state, indeed, of coma, and yet the patient gradually 
emerges from it and recovers. In the epidemic of 1872, in New York 
City, when the malady was new with us, many physicians predicted certain 
death, and employed remedies without expectation of any benefit on account 
of the apparently hopeless state of the patients, who seemed to be in pro- 
found coma, and yet not a few of them gradually and fully recovered. 

Digestive System,. — Vomiting, which is the most prominent symptom 
referable to the digestive system, has already been mentioned. Occurring 
early in the disease, it may cease in a few hours or not till after several days, 
and often it returns during the periods of recrudescence which are common 
in the progress of the fever. It occurs with little effort and without pre- 
vious nausea or with little nausea, as is usual when it has a cerebral origin. 
It does not differ as a symptom from the vomiting which is so common in 
other forms of meningitis. The substance vomited consists of the ingesta 



436 CONSTITUTIONAL DISEASES. 

and the secretions, as mucus and bile. Having a similar origin is a sensa- 
tion of faintness or depression, referred to the epigastrium. 

The appetite is usually impaired or lost during the active period of the 
attack, and it is not fully restored till convalescence is well advanced. 
Occasionally considerable nutriment is taken, and with apparent relish, as 
by one of my patients, twenty-eight years of age, who always had some 
appetite. Ordinarily, on account of repeated vomitings, constant febrile 
movements, impaired appetite and digestion, patients progressively lose 
flesh and strength, so that in protracted cases emaciation is always a promi- 
nent symptom, and is often extreme. Much emaciation and loss of strength, 
which attend many cases after the lapse of several weeks, greatly diminish 
the chances of a favorable termination. Thirst, already referred to, and 
constipation are common in this as in other forms of meningitis, but retrac- 
tion of the abdomen is not a notable symptom, except in protracted and 
greatly-wasted cases. The diarrhoea which is occasionally present in cerebro- 
spinal fever in the summer months must be regarded as a distinct disease 
and a complication. The tongue and the buccal and faucial surfaces present 
nothing unusual in their appearance. It is seldom, even in the most pro- 
tracted and emaciated cases, that the sordes and dry and brownish fur occur 
which are so common in typhus and typhoid fevers. The tongue is usually 
moist and but slightly furred. 

I have seen in consultation two patients that perished early with inability 
to swallow as the prominent symptom, attended in both by an abundant 
secretion upon the faucial surface, without any redness, swelling, or other 
evidence of inflammation. The early death of these young children, whose 
ages were ten months and two years, rendered the diagnosis less certain than 
in most other patients, but the attending physician as well as myself diag- 
nosticated cerebro-spinal fever with suddenly developed paralysis of the 
muscles of deglutition, so that no nutriment could be taken. If our under- 
standing of these interesting cases is correct, the paralysis was caused by 
lesion of that portion of the medulla oblongata which controls the function 
of deglutition, or else by injury of the intracranial portions of the nerves 
which supply the muscles concerned in this act. The following were the 
cases in question : 

, male, two years of age, became feverish and dull, but without 

vomiting, on October 22, 1882 ; axillary temperature, 102° F. On the fol- 
lowing day inability to swallow occurred, and the muscles of deglutition 
appeared wholly paralyzed. Death occurred on the third day, suddenly and 
apparently without suffering, as if from arrested function of important nerves, 
especially the pneumogastric. The abundant secretion of thin mucus or 
transudation of serum covering the faucial surface, and reaccumulating as 
soon as removed without any notable change in the appearance of the fauces, 
was remarkable. The physician in attendance, who for more than thirty years 
had had a large city practice, had seen no similar case, nor had I at the 
time. 

Soon afterward the second case occurred. An infant of ten months, with- 
out cough or embarrassment of respiration or faucial redness or swelling, lost 
the power of deglutition soon after the commencement of the supposed cere- 
bro-spinal fever, so that in the attempts to swallow the drinks entered the 
larynx, and the secretion or exudation was abundant, as in the other case. 
Death occurred in forty-eight hours. The rectal temperature was only 
101° F. 

In another case, which was ultimately fatal and in which the diagnosis of 
cerebro-spinal fever was certain, a robust girl, aged twelve, suddenly lost the 
power of deglutition at one time during her sickness, although she was 



CEEEBBO-SPIXAL FEVER. 437 

entirely conscious and repeatedly endeavored to swallow. The ability to 
swallow returned in a few days. 

Puke. — This is usually accelerated, and the more severe and dangerous 
the attack the more rapid is the heart's action, except occasionally in the 
comatose state, when, probably in consequence of compression of the brain 
from an abundant exudation, the pulse may be subnormal. Thus, in one of 
my patients, an adult, the pulse fell to 40 per minute, and in two others to 
between 60 and 70 per minute. With the exception of these three, the pulse 
in all cases which I have observed, so far as I recollect, has varied from the 
normal number of beats per minute to such frequency that it was difficult to 
count it. As death draws near the pulse ordinarily becomes more frequent 
and feeble. Intermissions in the pulse do not seem to be as common as in 
other forms of meningitis, but marked variations in its frequency during 
different hours of the day and on consecutive days constitute a conspicuous 
symptom. Thus, in a case which was fatal in the fifth week consecutive 
enumerations of the pulse in the acute stage were as follows : 128, 120, 88, 
130, 84, 112. 

Temperature. — Some of the older writers before the days of clinical ther- 
mometry stated that the temperature is not increased. North remarked as 
follows : •• Cases occur, it is true, in which the temperature is increased above 
the natural standard, but these are rare ;' 1 and Foot and Gallop make similar 
statements. Some recent writers have held the same opinion. Thus, Lidell 
wrote as follows in a treatise bearing the date of 1873 : " Febrile symptoms 
do not necessarily belong to epidemic cerebro-spinal meningitis as a substan- 
tive disease, for it may, and not unfrequently does, occur without exhibiting 
any such symptoms." We should naturally expect that meningitis, accom- 
panied as it is by active congestion of the brain and spinal cord, would pro- 
duce more or less fever, and in eighty-six cases which I examined by the 
thermometer I found elevation of temperature in every case during the acute 
stage, except in the beginning of the attack in two instances. In a young 
man aged twenty-eight years who had severe headache and seemed seriously 
sick the thermometer under the tongue showed no rise of temperature on the 
first and second days, but on the third day it was at 100° F.,and it remained 
elevated till his death on the thirteenth day. The second case was that of a 
young woman whom I saw in consultation, and who at the time of my visit 
had fever, but had none previously, according to the statement of the 
attending physician. 

In the 87 cases which I examined the heat of the surface occasionally 
did not seem above normal to the touch, and now and then the thermometer, 
applied in the axilla or groin, did not indicate fever, but the rectal temper- 
ature was always elevated above that of health after the disease was fully 
established. The temperature fluctuated from day to day and in different 
hours of the same day, but there was no exception to the rule that it was 
above the normal during the active stage of the malady after the first 
few days. Sometimes the elevation of temperature was slight, as in a female 
patient forty-seven years of age, in whom the thermometer showed no eleva- 
tion of temperature when it was placed in the mouth and axilla, but on 
introducing it into the rectum it rose to 99J° F. In the case of a young 
lady attended by me in 1890, having a very asthenic and fatal form of 
cerebro-spinal fever, accompanied by great prostration, a brown and dry 
tongue, and delirium, the temperature under the tongue was subnormal 
during the first two or three days, but was afterward above normal. 

The highest temperature which I have thus far observed was 107f° F., 
in a child aged two years. This was in the commencement of the attack. 
Subsequently it fell a little, but rose again on the third day to 107°. when 



438 CONSTITUTIONAL DISEASES. 

she died. In two other cases the temperature was 106° F. on the first day, 
and it did not afterward reach so high an elevation. One of these died on 
the ninth day, and the other in the ninth week. The next highest temper- 
ature was 105f F., also on the first day. in an infant aged eight months, who 
died on the ninth day. The first and last of these cases occurred in an old 
wooden tenement-house in the suburbs of the city and upon an elevated 
outcropping of rock. The highest temperature in any case in New York 
City which has come to my notice was observed in a male patient aged 
twenty-eight years who had active delirium, and died on the fifth day in 
Roosevelt Hospital. The temperature on the last day, taken four times, was 
as follows : 102 |°, 106f °, and, when the pulse had become imperceptible, 
109° and 107f° F. Wunderlich has recorded a temperature of 110° F. in 
one or two cases, but so great an elevation must be very rare, and is of 
course prognostic of an unfavorable ending. 

The external temperature undergoes still greater fluctuations than the 
internal, rising above and falling below the normal standard several times in 
the course of the same day. Similar fluctuations occur in other forms of 
meningitis, but they are, according to my experience, less pronounced than 
in cerebro-spinal fever, especially as I observed them in the epidemic of 
1872. Perhaps since that epidemic they have been less marked in the cases 
occurring in this city. The more grave the attack in those not comatose the 
greater these variations. The following is a common example of these 
sudden thermometric changes, occurring in a child of two years. The inter- 
nal temperature varied from 101° to 104-| o F. as the extremes, while that of 
the fingers and hands at the first examination was 90^°, at the second 90°, 
at the third 103°, and at the fourth 83°. Hence at the third examination 
the temperature of the extremities had risen 13°, so as nearly to equal that 
of the blood, and at the fourth examination it had fallen 20°. The patient 
recovered. These great and sudden variations in the pulse and the internal 
and external temperature have considerable diagnostic value in obscure and 
doubtful cases. 

Respiratory System. — This system is not notably involved in ordinary 
cases. Intermittent, sighing, or irregular respiration appears to be less 
frequent than in tubercular meningitis, but it does occur. In most patients 
the respiration is quiet, but somewhat accelerated, and without any marked 
disturbance in its rhythm. In thirty-one observations in children who had 
no complication, I found the average respirations 42 per minute, while the 
average pulse was 137. Therefore the respiration, as compared with the 
pulse, was proportionately more frequent than in health, due perhaps to the 
fact that certain muscles concerned in respiration, as the abdominal, are em- 
barrassed in their movements by tonic contraction. 

Various observers in different epidemics have recorded an unusual preva- 
lence of croupous pneumonia occurring simultaneously with cerebro-spinal 
fever. Bascome in his history of epidemics stated that " epidemic encepha- 
litis and malignant pneumonias prevailed in Germany in the sixteenth cen- 
tury" (Webber). Webber in his prize essay describes a variety of cerebro- 
spinal fever which he designates pneumonic, in which the cerebro-spinal axis 
is involved but slightly or not at all, and the brunt of the disease falls upon 
the respiratory organs. According to him. in certain epidemics the pneu- 
monic form has been common and in others infrequent. This fact is interest- 
ing taken in connection with the examination of the microbes of croupous 
pneumonia and cerebro-spinal fever, as detailed in our remarks under the 
head of etiology. 

Cutaneous Surface. — The features may be pallid, of normal appearance, 
or flushed in the first days of the disease, but in advanced cases they are 



CEREBROSPINAL FEVER. 439 

pallid, as is the skin generally. A circumscribed patch of deep congestion 
often appears, as in sporadic meningitis, upon some part of them, as the 
forehead, cheek, or an ear, and after a short time disappears. The hyper- 
aemic streak, the tache cerSbrale of Trousseau, produced by drawing the fin- 
ger firmly across the surface, also appears as in other forms of meningitis if 
the temperature of the surface be not too much reduced. 

The following are the abnormal appearances of the skin most frequently 
observed: 1. Papilliform elevations, the so-called goose-skin, due to contrac- 
tions of the muscular fibres of the corium. This is not uncommon in the 
first weeks. 2. A dusky mottling, also common in the first and second 
weeks in grave cases, and most marked when the temperature is reduced. 

3. Xumerous minute red points over a large part of the surface, bluish spots 
a few lines in diameter, due to extravasation of blood under the cuticle, 
resembling bruises in appearance, and large patches of the same color an 
inch or more in diameter, less common than the others, of irregular shape as 
well as size, and usually not more than two or three upon a patient. These 
last resemble bruises, and they may sometimes be such, received during the 
times of restlessness ; but ordinarily extravasations of this kind result 
entirely from the altered state of the blood. In New York in the epidemic 
of 1872 they were common, but since this epidemic, in the thirty-six cases 
which I have observed, I have rarely seen either the reddish points or the 
extravasations of blood. They were probably common in the epidemics in 
the first part of the century in this country, since the disease was desig- 
nated by the name " spotted fever " by the American physicians who wrote 
upon it at that time. That they are unusual in the European epidemics at 
the present time we infer from the fact that Yon Ziemssen expresses surprise 
that the disease should ever have been designated in America by such a title. 

4. Herpes. This is common. It sometimes occurs as early as the second or 
third day, but in other instances not till toward the close of the first week or 
in the second. The number of herpetic eruptions varies from six or eight to 
clusters as large as or larger than the hand. This cutaneous disease evi- 
dently has a nervous origin, its vesicles occurring in most instances on those 
parts of the surface which are supplied by branches of the fifth pair of 
nerves. Its most common seat is upon the lips, but occasionally it appears 
upon the cheek, upon and around the ears, and upon the scalp. Erythema 
and roseola, both transient skin eruptions, occasionally appear, and in one 
instance, in my practice, erysipelas occurred. During the first days the skin 
is frequently dry ; afterward perspirations are not unusual, and free per- 
spirations sometimes occur, especially about the head, face, and neck. 

Urinary Organs. — In other forms of meningitis it is well known that the 
quantity of urine excreted is usually diminished, but in this disease it is 
normal, and it may be more than normal. Polyuria has been noticed in dif- 
ferent cases by various observers. Mosler observed a boy aged seven years 
who had an excessive secretion of urine, which dated back to an attack of 
cerebro-spinal fever in his third year. The polyuria is probably due to 
injury of the nervous centre, since physiological experiment has demon- 
strated that irritation of the central end of the vagus, of certain parts of the 
cerebellum, and of the walls of the fourth ventricle sometimes produces this 
effect. The urine occasionally contains a moderate amount of albumen, and 
in exceptional instances cylindrical casts and blood-corpuscles. 

Arthritic inflammation, apparently of a rheumatic character, has been 
occasionally observed. It is commonly slight, producing merely an oedema- 
tous appearance around one or more joints. Thus in one case which came 
under my notice, and which was subsequently fatal, the parents, who were 
poor, and were therefore without medical advice till the case was somewhat 



440 CONSTITUTIONAL DISEASES. 

advanced, had already diagnosticated rheumatism on account of the puffiness 
which they had noticed around one of the wrists. 

The Special Senses. — Taste and smell are rarely affected, so far as is 
known, but it is possible that they are sometimes perverted, or even tempo- 
rarily lost, during the time of greatest stupor. In one case which I saw the 
sense of smell was entirely lost in one nostril, and I do not know whether it 
was ever fully restored. 

The affections of the eye and ear are important and of frequent occur- 
rence. Strabismus is common. It may occur at any period of the fever, 
continuing a few hours or several days, and it may appear and disappear 
several times before convalescence is established : occasionally it continues 
several weeks, after which the parallelism of the eyes is gradually and fully 
restored. In other instances it is permanent. 

Changes in the pupils are among the first and most noticeable of the 
initial symptoms, as I have already stated in describing the mode of com- 
mencement. These are dilatation, less frequently contraction, oscillation, 
inequality of size, feeble response to light, etc. Most patients present one 
or more of these abnormalities of the pupils, and they continue during the 
first and second weeks, and gradually abate if the course of the disease be 
favorable. Inflammatory hypersernia of the conjunctiva often occurs. It 
begins early, and now and then the conjunctivitis is so intense that con- 
siderable tumefaction of the lids results, with a free muco-purulent secre- 
tion. The false diagnosis has indeed been made of purulent ophthalmia in 
cases in which this affection of the lids was early and severe. But such 
intense inflammation is quite exceptional. More frequently there is a uni- 
form diffused redness of the conjunctiva, not so dusky as in typhus, and the 
injected vessels cannot be so readily distinguished as in that disease. 

In certain cases almost the whole eye (all, indeed, of the important con- 
stituents) becomes inflamed ; the media grow cloudy, the iris discolored, and 
the pupils uneven and filled up with fibrinous exudation. The deep struc- 
tures of the eye cannot, therefore, be readily explored by the ophthalmo- 
scope, but they are observed to be adherent to each other and covered by 
inflammatory exudation. They present a dusky-red or even a dark color 
when the inflammation is recent. Exceptionally the cornea ulcerates and 
the eye bursts, with the loss of more or less of the liquids and shrinking 
of the eye. " But ordinarily no ulceration occurs, and as the patient con- 
valesces the oedema of the lids, the hypersemia of the conjunctiva, the cloud- 
iness of the cornea and of the humors gradually abate and the exudation in 
the pupils is absorbed. The iris bulges forward, and the deep tissues of the 
eye, viewed through the vitreous humor, which before had a dusky-red color 
from hypersemia, now present a dull-white color." The lens itself, at first 
transparent, after a while becomes cataractous. Sight is lost totally and for 
ever. 

If the patient live, the volume of the eye diminishes, as the inflammation 
abates, to less than the normal size, even when there has been no rupture 
and escape of the fluids, and divergent strabismus is likely to occur. Prof. 
Knapp. whose description of the eye I have for the most part followed, says : 
c; The nature of the eye affection is a purulent choroiditis, probably metastatic." 
Fortunately, so general and destructive an inflammation of the eye as has been 
described above is comparatively rare. On the other hand, conjunctivitis of 
greater or less severity, and hyperemia of the optic disk, consequent upon 
the brain disease, are not unusual, but they subside, leaving the function of 
the organ unimpaired. " In some cases incurable blindness is noticed under 
the ophthalmoscope picture of optic nerve-atrophy, probably the sequence of 
choked disk " (Knapp). 



CEREBROSPINAL FEVER. 441 

Inflammation of the middle ear, of a mild grade and subsiding without 
impairment of hearing, is common. The membrana tympani during its con- 
tinuance presents a dull-yellowish, and in places a reddish, hue. Occasion- 
ally a more severe otitis media occurs, ending in suppuration, perforation of 
the membrani tympani. and otorrhoea, which ceases after a variable time. 
But otitis media is not the most severe of the affections of the organs of 
hearing. Certain patients lose their hearing entirely, and never regain it, and 
that, too. with little otalgia, otorrhoea, or other local symptoms by which so 
grave a result can be prognosticated. This loss of hearing does not occur at 
the same period of the disease in all cases. Some of those who become deaf 
are able to hear as they emerge from the stupor of the disease, but lose this 
function during convalescence, while the majority are observed to be deaf as 
soon as the stupor abates and full consciousness returns. 

Two important facts have been observed in reference to the loss of hearing 
in these patients — to wit, it is bilateral and complete. "When first observed it 
is. in some, as stated above, complete, but in others partial, and when partial it 
gradually increases till after some days or weeks, when it becomes complete. 
I have the records of 10 cases of this loss of hearing, most of them occurring 
in my own practice in the epidemic of 1872, but a few of them detailed to 
me by the physicians who observed them in the same epidemic. According 
to these statistics, about 1 in every 10 patients became deaf, but in the milder 
form of cerebro-spinal meningitis, which has prevailed since 1872, the pro- 
portionate number thus affected has been less among my patients, and 
the same may be said in reference to the loss of sight: 1 of the 10 cases 
was a young lady, but the rest were children under the age of ten years. 
Prof. Knapp has examined 31 cases. " In all/' says he, " the deafness was 
bilateral, and, with 2 exceptions of faint perceptions of sound, complete. 
Among the 29 cases of total deafness there is only 1 who seemed to give 
some evidence of hearing afterward." The same author has recently informed 
me that further experience has confirmed his previous statement, that while 
the blindness produced by cerebro-spinal fever is in the majority of cases 
monolateral, but one case had come to his notice in which the deafness was 
on one side only. 

One theory attributes the loss of hearing to inflammatory lesions, either 
at the centre of audition within the brain or in the course of the auditory 
nerves before they enter the auditory foramina. The other theory, which is 
the better established of the two and must be accepted, attributes the loss 
of hearing to inflammatory disease of the ear, and especially of the labyrinth. 

Symptoms of Endemic or Naturalized Cerebro-spinal Fever. — 
The numerous monographs on this disease which have appeared during the 
last few years relate to its epidemic form, and no published observations, so 
far as I am aware, describe the character or symptoms which it presents or 
the changes which it undergoes when it occurs as an endemic or naturalized 
disease. The endemic disease must, of course, be observed in the cities or 
populous towns, for there is no rural locality, so far as I am aware, in which 
this disease is permanently established. In New York the naturalized disease 
appears to be accompanied by a less profound blood-change than occurs in 
epidemic cases. Although every year seeing a considerable number of cases, 
I have not in the last ten years seen one with the livid spots upon the surface, 
due to subcutaneous extravasation of blood, which were so common in the 
epidemic of 1872, and which have been so common in epidemics both in this 
country and in Europe that the term " spotted fever " was applied to the 
malady. Occasionally petechise occur in severe cases of the naturalized 
disease. 

Nature. — The theory that cerebro-spinal fever is a local disease, occur- 



442 



CONSTITUTIONAL DISEASES. 



ring epidemically, was commonly held in the first part of this century, but is 
now discarded. Job Wilson in 1815 considered it a form of influenza, and 
could see no utility in drawing a distinction between spotted fever and influ- 
enza. We at the present time can see no resemblance between the two, ex- 
cept that both occur as epidemics. The theory that cerebro-spinal fever is a 
peculiar local disease, occurring in epidemics, is more plausible than that which 
holds that it is a form of influenza. Even Niemeyer says that it presents no 
symptoms except such as are referable to the local affection. But the evi- 
dence is strong that cerebro-spinal fever is a constitutional malady with the 
meningitis as a local manifestation, just like measles with its bronchitis or 
scarlet fever with its pharyngitis. The abrupt and severe commencement, 
unlike that of those forms of meningitis which are known to be strictly local, 
and the early blood-change, as shown in certain cases by the appearance of 
the skin and extravasation under it, indicate a general disease. Constitutional 
diseases having prominent local symptoms and lesions are usually regarded at 
first as local. It is only as time goes on and they are more thoroughly studied 
and understood, and clinical observations multiply, that their constitutional 
nature is recognized. 

The theory that cerebro-spinal fever is a form of typhus once had advo- 
cates, but it is now so generally discarded as untenable and absurd that it 
would be a waste of time to consider the facts which differentiate the two 
maladies. Cerebro-spinal fever should therefore be considered as distinct 
from all other diseases, a malady sui generis, and in nosological writings it 
should be classified with those constitutional maladies which have specific 
causes. 

Although this disease ordinarily occurs in an epidemic form in localities 
widely separated from one another, and, after continuing a few weeks or 
months, totally disappears, perhaps never to return or not till after the lapse 
of years, nevertheless in localities it becomes established, so that it is proper 
to describe it as an endemic — a fact to which we have already referred as 
regards certain American cities. I do not know that it is endemic in any 
village or rural locality in this country. The large cities, with their promis- 
cuous population, foreign and native, their crowded tenement-houses, and 
their many sources of insalubrity, furnish in an eminent degree the condi- 
tions which are favorable for the development and perpetuation of the mi- 
crobic diseases. Those diseases which in the present state of our knowledge 
we have reason to believe are caused by micro-organisms, we should expect to 
prevail most where domiciles are crowded and filthy, and systems are enervated 
by impure air, hardships, and privation. Hence in New York City, in the 
crowded quarters of the poor, cerebro-spinal fever, like diphtheria, is seldom 
or never absent. 



1872 
1873 
1874 
1875 
1876 
1877 
1878 
1879 



Deaths in New York from Cerebro- Spinal Fever. 
Number. 



782 


1880 


290 


1881 


158 


1882 


146 


1883 


127 


1884 


116 


1885 


97 


1886 


108 


1887 



Number. 

. 170 

. 461 

. 238 

. 223 

. 210 

. 202 

. 223 

. 203 



It is seen that the greatest mortality was in the first year after the introduc- 
tion of the disease into the city, after which the number of deaths gradually 
diminished, year by year, till 1878, when the lowest mortality was reached. 



CEREBROSPINAL FEVER. 443 

After 1S7S the mortality gradually increased till 1881, in which year the 
number of deaths was double that of any other year except 1872. 

The mortuary reports of Philadelphia likewise show that cerebro-spinal 
fever has remained in that city since its introduction in 1863, a period of 
twenty-five years, the annual deaths produced by it varying between 36, the 
minimum, in 1869 and 1870, and 384, the maximum, in 1864. In Providence 
also, as appears from Dr. Snow's reports, cerebro-spinal fever has caused an- 
nually more or fewer deaths since 1871. Therefore, we repeat, this fact may 
be added to the sum of our knowledge of this disease, that, once gaining a 
lodgement where the conditions are favorable for it, as in a large city, it may 
become established and remain an indefinite time. 

Anatomical Characters. — I have notes of the post-mortem appearances 
in 76 cases, published chiefly in British and American journals : 29 died within 
the first three days, 28 between the third and twenty-first days, and the dura- 
tion of the remaining 19 was unknown. These records furnish the data for 
the following remarks : 

The blood undergoes changes which are due in part to the inflammatory 
and in part to the constitutional and asthenic nature of the disease. The pro- 
portion of fibrin is increased in cases that are not speedily fatal, as it ordi- 
narily is in idiopathic inflammation. Analyses of the blood by Ames, 
Tourdes, and Maillot show a variable proportion of fibrin from three and 
four-tenths to more than six parts in one thousand. In sthenic cases accom- 
panied by a pretty general meningitis, cerebral and spinal, there is, after the 
fever has continued some days, the maximum amount of fibrin, while in the 
asthenic and suddenly fatal cases, with inflammation slight or in its com- 
mencement, the fibrin is but little increased. The most common abnormal 
appearance of the blood observed at autopsies is a dark color, with unusual 
fluidity and the presence of dark soft clots. Exceptionally bubbles of gas 
have been observed in the large vessels and the cavities of the heart. An 
unusually dark color of the blood, small and soft dark clots, and the presence 
of gas-bubbles, when only a few hours have elapsed 'after death, indicate a 
malignant form of the disease, in which the blood is early and profoundly 
altered. In certain cases this fluid is not so changed as to attract attention 
from its appearance. The points or patches of extravasated blood which are 
observed in and under the skin during life in some patients usually remain in 
the cadaver. When an incision is made through them the blood is seen to 
have been extravasated, not only in the layers of the skin, but also in the sub- 
cutaneous connective tissue. Extravasations of small extent are likewise 
sometimes observed upon and in thoracic and abdominal organs. 

In those who die after a sickness of a few hours or days — namely, in 
the stage of acute inflammatory congestion — the cranial sinuses are found 
engorged with blood and containing soft dark clots. The meninges envelop- 
ing the brain are also intensely hyperaemic in their entire extent in most 
cadavers, but in some cases the hyperaemia is limited to a portion of the 
meninges, while other portions appear nearly normal. In those cases which 
end fatally within a few hours this hyperaemia is ordinarily the only lesion 
of the meninges ; but if the case be more protracted, serum and fibrin are 
soon exuded from the vessels into the meshes of the pia mater, and under- 
neath this membrane over the surface of the brain. Pus-cells also occur 
mixed with the fibrin, sometimes so few that they are discovered only with 
the microscope, but in other cases in such quantity as to be much in excess 
of the fibrin and to be readily detected by the naked eye. Pus. which in 
these cases probably consists of white blood-corpuscles which have escaped 
with the fibrin from the meningeal vessels, often appears early in the attack. 
The arachnoid soon loses its transparency and polish, and presents a cloudy 



44-4 COXSTITUTIOXAL DISEASES. 

appearance over a greater or less extent of its surface. The cloudiness is 
usually greatest along the course of the vessels in the sulci and depressions, 
and where the fibrinous exudation is greatest, but it occurs also in places 
where no such exudation is apparent to the naked eye. 

The exudation — serous, fibrinous, and purulent — occurs, as in other forms 
of meningitis, within the meshes of the pia mater, and underneath this mem- 
brane over the surface of the brain. The fibrin is raised from the surface of 
the brain with the meninges in making the autopsy. It is most abundant in 
the intergyral spaces, around the course of the vessels, over and around the 
optic commissure, pons Varolii, cerebellum, and medulla oblongata, and along 
the Sylvian fissures. It is most abundant in the depressions, where it some- 
times has the thickness of one-tenth to one-fourth of an inch, but it often 
extends over the convolutions so as to conceal them from view. 

Most other forms of meningitis have a local cause, and are therefore 
limited to a small extent of the meninges — as, for example, meningitis from 
tubercles or caries of the petrous portion of the temporal bone, in both of 
which it is commonly limited to the base of the brain ; or from accidents, 
when the meningitis commonly occurs upon the side or summit of the brain. 
The meningitis of cerebro-spinal fever, on the other hand, having a general 
or constitutional cause, occurs with nearly equal frequency upon all parts of 
the meningeal surface, except that it is perhaps most severe in the depres- 
sions, where the vascular supply is greatest. In cases of great severity the 
inflammatory exudation, fibrinous or purulent, or both, covers nearly or quite 
the entire surface of the brain. 

In those who die at an early stage of the attack the vessels of the brain, 
like those of the meninges, are hypersemic. so that numerous " puncta vas- 
culosa " appear upon its incised surface. At a later period this hyperaeruia, 
like that of the meninges, may disappear. If there be much effusion of 
serum within the ventricles and over the surface of the brain, the convolu- 
tions are liable to be flattened, and the pressure may be so great that the 
amount of blood circulating in the brain is reduced below the normal quan- 
tity. Thus, in the case of a child of three years who lived sixteen days, and 
was examined after death by Burdon-Sanderson. the ventricles contained a 
large amount of turbid serum and the brain-substance was everywhere pale 
and anaemic from compression. 

Cerebral ramolUssement occurs in certain cases. At one of the examina- 
tions in Charity Hospital, the patient having been only three days sick, the 
brain was found much softened. The dissection was made seven hours after 
death, so that the softening could not have been the result of decomposition. 
At one of the post-mortem examinations in Bellevue Hospital, softening 
of the fornix, corpus callosum, and septum lucidum was observed, and in 
another softening in the neighborhood of the subarachnoid space. In a case 
related by Dr. Moorman 1 it is stated that portions of the brain, medulla 
oblongata, and pons Varolii were softened. In a case observed by Dr. Uphani 
softening of the superior portion of the left cerebral hemisphere had occurred. 
Occasionally the whole brain is somewhat softened. Burdon-Sanderson, Rus- 
sell, and Githens each relate such a case. Moreover, the walls of the lateral 
ventricles are ordinarily more or less softened in fatal cases of cerebro-spinal 
fever, as they are in other forms of meningitis. In rare instances the brain 
is cedematous, as in a case published by Dr. Hutchinson. 2 In this case the 
patient was only four days sick and the whole brain was oedematous, serum 
escaping from its incised surface. 

The ventricles contain liquid, in some patients transparent serum, in 
others serum turbid and containing flocculi of fibrin or fibrin with pus. The 

1 American Journal of the Medical Sciences, October, 1866. 2 Ibid., July, 1866. 



CEREBRO-SPIXAL FEVER. 445 

liquids in the different ventricles, since they intercommunicate, are the same. 
The choroid plexus is either injected or it is infiltrated with fibrin and pus, 
With the abatement of the inflammation, absorption commences. The serum, 
from its nature, is readily absorbed, and the pus and fibrin more slowly by 
fatty degeneration and liquefaction. Occasionally the serum remains, and 
chronic hydrocephalus results. An infant who contracted the disease at the 
age of five months, and appeared to be convalescent, had, two months sub- 
sequently, great prominence of the anterior fontanel, and other symptoms 
indicating the presence of a considerable amount of effusion within the 
cranium. In another case, one year afterward, examination showed the 
enlargement of the head and prominence of the fontanel which characterize 
chronic hydrocephalus. A boy of ten years treated in Roosevelt Hospital in 
1878 died three months after the commencement of cerebro-spinal fever. 
The records of the autopsy state : " Body a skeleton ; brain, dura mater, and 
pia mater appear normal, except a little thickening of latter at base of brain ; 
ventricles much enlarged and full of clear serum ; surface of walls of ven- 
tricles appears normal, but is soft ; spinal cord and membranes apparently 
normal ; heart, lungs, stomach, and intestines normal ; liver congested ; kid- 
neys pale." In this case, therefore, all the other lesions of the cerebro-spinal 
axis, except the serous effusion, had nearly disappeared. No post-mortem 
examinations, so far as I am aware, have yet revealed the state of the brain 
and its meninges in those who have had this malady at some former time, and 
have fully recovered. Whether there may not be some traces of it which are 
permanent, as opacity or adhesions, must be determined by future observations. 

The remarks made in reference to the cerebral apply, for the most part, 
also to the spinal meninges. There is at first intense hyperemia of the 
membranes, usually over the entire surface of the cord, soon followed by 
fibrinous, purulent, and serous exudation in the meshes of the pia mater and 
underneath this membrane. This exudation is sometimes confined to a por- 
tion of the meninges, more frequently that covering the posterior than the 
anterior aspect of the cord, and when it is general it is ordinarily thicker 
posteriorly than anteriorly. In severe cases nearly or quite the entire spinal 
pia mater may be infiltrated by inflammatory products. Thus, in the case of 
an infant that died of cerebro-spinal fever at the age of ten weeks, in the 
service of Dr. H. D. Chapin in the Out-door Department at Bellevue, the 
entire spinal cord was covered by a fibrino-purulent exudation, except a space 
about six lines in extent upon the anterior surface. 

No constant or uniform lesions occur in the organs of the trunk, and 
those observed are not distinctive of this disease. Hypostatic congestion 
of the lungs, bronchitis, atelectasis, and broncho-pneumonia are common. 
Pleuritic, endocardial, and pericardial inflammations have occasionally been 
observed, but are rare. Effusion of serum, sometimes blood-stained, occasion- 
ally occurs in the pleural and other serous cavities. The auricles and ven- 
tricles of the heart, as already stated, contain more or less blood, with soft 
dark clots in the more malignant and rapidly fatal cases, but larger and firmer 
in those which have been more protracted. The spleen is enlarged in less 
than half the patients. The absence of uniformity as regards the state of 
the spleen, the fact that in many it undergoes no appreciable change, is 
important, since this organ is so generally enlarged and softened in the infec- 
tious diseases. The stomach, intestines, and liver are sometimes more or less 
congested, but in other cases their appearance is normal. The agminate and 
solitary glands of the intestines have ordinarily been overlooked, but in cer- 
tain cases they have been found prominent. The kidneys are normal, or they 
exhibit the lesions of nephritis. In 1 of 8 autopsies made by Prof. Welch 
acute diffuse nephritis had been present, as shown by the state of the kidneys. 



446 CONSTITUTIONAL DISEASES. 

In the case of a child of nine years treated by Dr. F. A. Burrall in the 
Presbyterian Hospital the urine was very albuminous and the kidneys pre- 
sented a fatty appearance. Anatomical changes in these organs, however, are 
not common, unless in slight degree, so that in most patients their, function 
is fully and properly performed. 

Prognosis. — Cerebro-spinal fever is justly regarded as one of the most 
dangerous maladies of childhood. It is dreaded not only on account of the 
great mortality which attends it, but also on account of its protracted course, 
the suffering which it causes, the possible permanent injury of the important 
organ which is chiefly involved, and the irreparable damage which the eye 
and ear often sustain. 

I have the records of the result in 52 cases which I attended or saw in 
consultation in the epidemic of 1872. Of these just one-half recovered. 16 
of the 26 who died were hopelessly comatose within the first seven days, 
most of them dying within that time, and some even on the first and second 
days, while others of the 16 lingered into the second week and died without 
any sign of returning consciousness. The remaining 10, who subsequently 
died, but did not become comatose in the first week, were nevertheless seri- 
ously sick from the first day, but their symptoms, though severe, were not 
such as necessarily indicated a fatal result, so that there was some expecta- 
tion of a favorable ending till near death, which occurred for the most part 
from asthenia. One succumbed to purpura haemorrhagica, the hemorrhages 
occurring from the mucous surfaces. The patient died after a sickness of 
more than two months, in a state of extreme emaciation and prostration. The 
26 who recovered convalesced slowly, and usually after many fluctuations. 
Their highest temperature and most severe and dangerous symptoms occurred 
in the first week. Most of them were several weeks under observation and 
treatment before they sufficiently recovered to be out of danger. The statis- 
tics of this epidemic therefore show — and the same is true of other epidemics 
— that the first week is the time of greatest danger, and if no fatal symp- 
toms are developed during this week, recovery is probable with proper thera- 
peutic measures and kind, intelligent, and efficient nursing, which is very 
important. 

Since 1872 I have seen a larger number, and have preserved records of 
40 cases which I was able to follow to the close. Some were seen in consul- 
tation. Of these 40, 21 recovered and 19 died. Of the 19 fatal cases, 9 died 
in the first week, 5 in the second week, 1 in the third week, 1 on the twenty- 
fifth day, 1 on the thirty-first day, and 1 in the sixteenth week. This last 
patient, a boy of ten years, would, in my opinion, have recovered with better 
nursing. His death occurred from large bed-sores which extended to the 
bones, produced by lying a long time in one position on a hard bed when he 
was too weak to move, and often with soiled bedclothes underneath him. 
The remaining case of the 19 died after a prolonged sickness. 

There is probably no disease which falsifies the predictions of the phy- 
sician more frequently than cerebro-spinal fever. This is due partly to the 
severity of the cerebral symptoms in the commencement, which, did they 
occur in other forms of meningitis with which he is more familiar, would 
justify an unfavorable prognosis, and partly to the remissions and exacerba- 
tions, the occurrence alternately of symptoms of apparent convalescence and 
recrudescence or relapse, which characterize the course of this malady. Grave 
initial symptoms, which may appear to have a fatal augury, are often fol- 
lowed by such a remission that all danger seems past, and in a few hours 
later perhaps the symptoms are nearly or quite as grave as at first. 

Under the age of five years and over that of thirty the prognosis is less 
favorable than between these ages. An abrupt and violent commencement. 



CEREBROSPINAL FEVER. 447 

profound stupor, convulsions, active delirium, and great elevation of tempera- 
ture are symptoms which should excite solicitude and render the prognosis 
guarded. " If the temperature remain above 105° F., death is probable, even 
with moderate stupor. Numerous and large petechial eruptions show a pro- 
foundly altered state of the blood, and are therefore a bad prognostic ; and so 
is continued albuminuria, since it shows great blood-change or nephritis, while 
other organs than the kidneys are probably so involved. In one case, a boy 
whom I examined nearly a year after the cerebro-spinal fever, the kidneys 
were still affected. He had anasarca of the face and extremities, with albu- 
minuria. Chronic Bright 's disease had occurred from the acute nephritis 
which complicated cerebro-spinal fever. Profound stupor, though a danger- 
ous svmptom, is not necessarily fatal so long as the patient can be aroused to 
partial consciousness and the pupils are responsive to light ; so long as it 
does not pass into actual coma it is less dangerous than active or maniacal 
delirium, which is likely to eventuate in this coma. 

A mild commencement with general mildness of symptoms, as the ability 
to comprehend and answer questions, moderate pain and muscular rigidity, 
some appetite, moderate emaciation, little vomiting, etc., justify a favorable 
prognosis, but even in such cases it should be guarded till convalescence is 
fully established. 

We may repeat and emphasize the important fact shown by the above 
statistics, that patients who live till the close of the second week without 
serious complications will probably recover. The danger after this period 
is, in most instances, from exhaustion and feeble action of the heart, result- 
ing from the impaired nutrition and the protracted course of the disease. 

Complications which most frequently pertain to the lungs increase greatly 
the gravity of many cases and contribute to the fatal ending. The fact that 
Webber in his prize essay describes a variety of cerebro-spinal fever which he 
designates pneumonic, and that those who make post-mortem examinations 
find that " oedema, hypostatic congestion of the lungs, bronchitis, atelectasis, 
and broncho-pneumonia are extremely common lesions in cerebro-spinal men- 
ingitis " (Welch), indicate a source of danger in addition to that located in 
the cerebro-spinal system. One close observer of an epidemic writes : " In 
all the fatal cases which came under my notice the most prominent symptoms 
which preceded death were those which indicate impairment and perversion 
of the respiratory functions. As the breathing became more hurried and 
difficult the general depression became more intense, the pulse became weaker 
and quicker, and the temperature of the skin more elevated." 

Parenchymatous degeneration of the liver and kidneys is another serious 
complication. The kidneys are probably more frequently, and to a greater 
extent, diseased than the liver. We have already stated that nephritis was 
present in 1 of the 8 cases examined by Prof. Welch. In the Revue medi- 
cate for June 3, 1882, M. Ernest Gandier published the case of a female 
who died comatose on the sixth day of cerebro-spinal fever. Examination 
of the urine had revealed the presence of " retractile albumen of Prof. 
Bouchard, attributable to renal lesions, and non-retractile albumen, consid- 
ered as an indication of some general infection of the system." Microscopic 
examination of the kidneys " showed considerable swelling and granular 
degeneration of the renal epithelial cells, with effusion of granular matter 
within the lumina of the tubules." We have seen from the case referred to 
above that the renal complication may persist and become chronic. Those 
who fully recover often exhibit symptoms, usually of a nervous character, as 
irritability of disposition, headache, etc., for months or years after conva- 
lescence is established. 

Diagnosis. — Cerebro-spinal fever, on account of the nature and severity 



448 CONSTITUTIONAL DISEASES. 

of its symptoms and the suddenness of its onset, may be mistaken for scarlet 
fever, and vice versa. In one instance, to my knowledge, this mistake was 
made. High febrile movement, vomiting, convulsions, and stupor are common 
in the commencement of scarlet fever, and the same symptoms commonl} x usher 
in the severer forms of cerebro-spinal fever. It will aid in diagnosis to ascer- 
tain whether there be redness of the fauces, for this is present in the commence- 
ment of scarlet fever, and a few hours later the characteristic efflorescence 
appears on the skin. 

The diagnosis of cerebro-spinal fever from the common forms of menin- 
gitis is ordinarily not difficult, for while in the former the maximum inten- 
sity of symptoms occurs in the first days, in the latter there is gradual and 
progressive increase of symptoms from a comparatively mild commencement. 
Moreover, cases of ordinary or sporadic meningitis occurring at the age 
when cerebro-spinal fever is most frequent are commonly secondary 1 , being 
due to tubercles, caries of the petrous portion of the temporal bone, or other 
lesion, and are therefore preceded and accompanied by symptoms which are 
directly referable to the primary disease. We have seen how different it is 
in cerebro-spinal fever, which in most patients begins abruptly in a state of 
previous good health. Again, in cerebro-spinal fever after the second or 
third day hyperesthesia, retraction of the head, and other characteristic 
symptoms occur, which are either not present or are much less pronounced 
in ordinary meningitis. Some of the milder cases of cerebro-spinal fever 
might be mistaken for hysteria, but the pain in the head and elsewhere, the 
muscular rigidity, and especially the occurrence of more or less fever, enable 
us to make the diagnosis. Continued fever, typhus or typhoid, resembles 
cerebro-spinal fever in certain particulars, but it lacks the muscular contrac- 
tion and rigidity which characterize the latter. It does not usually begin so 
abruptly, with such severe symptoms, especially such severe headache, has 
less marked fluctuations, and a more definite duration. These facts in con- 
nection with the character of the prevailing epidemic will enable us to make 
the diagnosis. In one instance commencing retro-pharyngeal abscess, prob- 
ably associated with vertebral caries, was at first mistaken by me for cerebro- 
spinal fever. The patient was an infant, had a temperature of 104° F.. stiff- 
ness of the neck, with some retraction of the head, and cried from pain 
when the head was brought forward. The speedy occurrence of two large 
abscesses in other parts of the system, difficult deglutition, and noisy respi- 
ration, led to a digital exploration of the fauces, when the abscess was found 
and opened. 

Treatment. — Since, in epidemics of cerebro-spinal fever cases are more 
frequent and severe where antihygienic conditions exist, it is evident that 
measures looking to the removal of such conditions, measures designed to pro- 
cure pure air in the domicile, wholesome diet, and a quiet and regular mode 
of life — in fine, measures designed to produce the highest degree of health — 
are of the first importance for the prevention of the disease. Cleanliness of 
the streets and areas, as well as of the apartments, good sewerage and drain- 
age, the prompt removal of all refuse matter, avoidance of overcrowding — in 
a word, the strict observance of sanitary requirements in every particular — 
will, there can be little doubt from what we know of the causation and nature 
of cerebro-spinal fever, diminish the number and severity of the cases. The 
avoidance of fatigue and overwork and of mental excitement, the use of plain 
and wholesome diet, sufficient sleep, the utmost regularity in the mode of life, 
with the least possible exposure to depressing agencies, are the important pre- 
ventive measures which should be recommended during an epidemic of cere- 
bro-spinal fever. 

The enjoining of a quiet and regular mode of life as a preventive measure 



CEREBROSPINAL FEVER. 449 

during the occurrence of an epidemic of cerebro-spinal fever is not inconsist- 
ent with the theory that the cause is a micro-organism. It is not unreason- 
able to suppose that the system may be more or less under the influence of 
the specific principle, and that this principle may obtain lodgement in the blood 
or tissues without result until some exciting cause occurs which depresses the 
system and disturbs the functions, when the resisting power fails and cerebro- 
spinal fever appears ; just as those exposed to Asiatic cholera may remain well 
until some imprudence in the diet or the mode of life causes an outbreak of 
the malady. 

Curative Treatment. — In the commencement of cerebro-spinal fever in- 
tense inflammatory congestion occurs of the cerebral and spinal meninges, and 
also to a certain extent of the brain and spinal cord. As regards treatment, 
the obvious indication is to reduce the hyperaemia of the vessels as quickly 
as possible and subdue or diminish the inflammation. For this purpose bags 
or bladders of ice should be immediately applied over the head and to the 
nucha, and constantly retained there as long as there is no complaint of chil- 
liness, no marked diminution of temperature, and the patient experiences some 
relief from the intense headache and other symptoms. Bran mixed with 
pounded ice produces a more uniform coldness and is sometimes more agree- 
able to the patient than the ice alone. The bag or bags should be about 
one-third full, so as to fit upon the head like a cap, and the nurse should be 
instructed to renew the ice as soon as it melts. In severe cases with marked 
elevation of temperature it is proper to apply cold over the dorsal and lum- 
bar vertebrae, as well as upon the head and nucha. A hot mustard foot-bath 
or a general warm bath in those cases in which convulsions are present or 
threatening, or in which there is delirium or great agitation or severe 
peripheral pains, is also useful, since it has a calmative effect and acts as 
a derivative from the hyperaemic nerve-centres. One writer states that he 
obtained marked benefit in a case by immersing the body to the neck in hot 
water. 

The abstraction of blood, usually by leeches applied to the temples, be- 
hind the ears, or along the spine, has been employed, but even in the com- 
mencement of the present century, when it was customary to bleed generally 
and locally in the treatment of inflammatory and febrile diseases, a majority 
of the American physicians, whose writings are extant, discountenanced the 
abstraction of blood in the treatment of this disease. Drs. Strong, Foot, and 
Miner, though under the influence of the Broussaisian doctrine, were good 
observers, and they soon abandoned the use of the lancet and leeches in the 
treatment of these patients for more sustaining measures. Strong 1 states that 
certain physicians employed venesection as a means of relieving the internal 
congestions, but, finding that the pulse became more frequent after a mode- 
rate loss of blood, they soon laid aside the lancet. Some experienced physi- 
cians of that period, however, continued to recommend and practise deple- 
tion, general as well as local, as for example, Dr. Gallop, who treated many 
cases in Vermont in the epidemic of 1811. 

Venesection in the treatment of cerebro-spinal fever is universally dis- 
carded at the present time in this country and Europe, but some intelligent 
physicians, as Sanderson and Niemeyer. approve of local bleeding in certain 
cases. It is. in my opinion, after examining the histories of many cases, uncer- 
tain whether the abstraction of blood should ever be recommended, but if it 
be prescribed it should be on the first day, when the hyperaemia is greatest. 
by the application of only a few leeches behind the ears, and never except 
when coma or convulsions are present or threatening and the patient is robust. 
The fact should not be forgotten that cerebro-spinal fever is in its nature 
1 Medical and Physiological Register, 1811. 
29 



450 CONSTITUTIONAL DISEASES. 

asthenic and protracted, and that the intense inflammatory congestion of the 
nervous centres can ordinarily be relieved, if relieved at all, by the other 
measures recommended, which do not reduce the strength. The alarming 
symptoms which usher in an attack, the intense headache, restlessness, delir- 
ium, sometimes eclampsia or coma, seem to demand the most energetic treat- 
ment, and yet it is surprising to one who has his first experiences with this 
malady how patients under proper treatment, without the abstraction of 
blood, emerge from an apparently almost hopeless state and ultimately recover. 
There may be total unconsciousness, the pupils dilated like rings and insensible 
to light, the head intensely hot, tonic convulsions present or alternating with 
frequent clonic convulsions, and yet these symptoms, which in any other 
disease would be regarded as sufficient to justify the prognosis of certain 
death, may gradually pass off toward the close of the first or in the second 
week, and the case afterward progress favorably. In the New York epidemic 
of 1872 — previous to which physicians of this city had no personal expe- 
rience with cerebro- spinal fever — many cases were pronounced hopeless which 
ultimately did well without abstraction of blood. In a case occurring in the 
practice of Dr. Griswold the patient was comatose for three days, with pupils 
not responding or but very feebly responding to light, but he recovered with- 
out the abstraction of blood and with the remedies ordinarily employed. In 
a case which we will presently relate in speaking of another local treatment 
the patient was still unconscious in the third week, with pupils greatly dilated 
and insensible to light, and yet recovered without losing blood. Such cases 
show that the most urgent symptoms, such as seem to indicate the prompt 
employment of leeches in order to reduce the meningeal hyperaemia and the 
consecutive congestion of the nerve-centres, may be relieved and the patient 
recover without such depletion, and with the preservation of the blood, which 
is so much needed in the subsequent asthenic course of the malady. 

In only one case have I recommended the abstraction of blood, and this 
was so instructive that I will briefly relate it : A girl four years of age was 
seized on March 7, 1873, with vomiting, chilliness, and trembling, followed 
by severe general clonic convulsions lasting about fifteen minutes ; was semi- 
comatose ; pulse 132, and a few hours later 156 ; temperature 101i° F. ; 
respiration 44 ; eyes closed, pupils moderately dilated and feebly responsive 
to light ; dusky mottling of skin, constant tremulousness with twitching of 
limbs. Bromide of potassium was administered in hourly doses of four grains, 
ice applied to the head and nucha, and a hot mustard foot-bath followed by 
sinapisms to the nucha. On the following day, March 8th, she was partly 
conscious when aroused, but immediately relapsed into sleep ; head retracted ; 
bowels constipated ; pulse 136 ; temperature 102° ; vomited occasionally. It 
was thought proper, on account of the extreme stupor, to apply one leech to 
each temple, and the bites trickled slowly nearly five hours. The other treat- 
ment was continued. On the 9th the pulse was 180 — so feeble that it was 
counted with difficulty; temperature 101|°. The patient was evidently sink- 
ing. It was necessary to order whiskey in teaspoonful doses every two hours, 
with beef tea and other most nutritious drinks. Evening, pulse 172, still 
feeble. March 10th, pulse 180, barely perceptible; great hyperesthesia ; 
axillary temperature 100° ; axis of eyes directed downward. After this the 
patient gradually rallied for a time, the pulse becoming stronger and less 
frequent, but death finally occurred after nine weeks in a state of extreme 
emaciation and exhaustion. Slight convulsions occurred in the last hours. 

It is seen that in the above case, which may be regarded as typical, the 
patient passed into a state of extreme prostration after the application of the 
leeches, so that for three days I did not believe that she would live from 
hour to hour, and death occurred after an illness of nine weeks, apparently 



CEREBROSPINAL FEVER. 451 

from sheer exhaustion. Experience like this, which corresponds with that 
of most other observers, shows the necessity of preserving the blood, and 
thereby the strength, however urgent the initial symptoms, inasmuch as 
cerebro-spinal fever in its subsequent course is attended by such marked 
asthenia. On May 3, 1878, a boy of ten years was admitted into one of the 
New York hospitals in the service of a prominent physician. It was stated 
that he had been four days sick with cerebro-spinal fever, and among other 
characteristic symptoms he had had delirium every night, and on May 2d 
delirium in the day-time, which had abated considerably after free epistaxis. 
In the hospital the application of ten leeches along the spine was ordered, 
but it does not appear to have diminished the delirium or any other symp- 
tom, and the following day the pulse was so frequent and feeble that active 
stimulation by brandy was resorted to. He had three strong convulsions on 
May 13th. which were relieved by ice to the head and nape of neck and by 
six minims of Magendie's solution. Severe pains occurred at times in the 
back and limbs, and on the 29th, one month after the commencement of the 
disease, the same pain frequently recurring, twelve leeches were ordered to 
be applied to the spine. On June 2d the limbs were flexed and quite stiff, 
and the effort to move them was attended by great pain. The pain in the 
back was also more constant, and in consequence sixteen leeches were applied 
to the spine. The next day there was no pain, but the patient was very 
stupid. On June 6th the records state that he was obviously losing strengh 
day by day — that his emaciation was extreme and his anaemia very marked. 
But he had very great vitality, and, although he had strabismus, bed-sores, 
incontinence of urine and feces, and extreme prostration, he lingered till 
August 1st, At the autopsy: " Body a skeleton; brain, dura mater, and pia 
mater appear normal, except a little thickening of latter at base of brain ; 
ventricles much enlarged and full of clear serum ; surface of walls of ven- 
tricles looks normal, but is soft ; spinal cord and membranes appear normal 
to the naked eye." No disease was discovered in other organs, except that 
the liver appeared congested and the kidneys pale. It can scarcely be doubted 
that although some temporary relief from the pain may have resulted to this 
patient by the repeated application of leeches, which diminished the menin- 
geal hyperemia, yet his chances for ultimate recovery would have been far 
better without such depletion. Therefore the histories of cases show that 
the result of abstraction of blood has been unsatisfactory, on account of the 
asthenic nature and protracted course of cerebro-spinal fever, and it should 
never be recommended as a remedial agent. 

Some benefit is apparently derived from the application of stimulating 
and moderately irritating lotions along the spine. A liniment consisting of 
equal parts of camphorated oil and turpentine briskly applied by friction 
with flannel up and down the spine till redness is produced, appears to cause 
some alleviation of the suffering, and it does not conflict with the use of the 
ice-bag. Dr. William H. Sutton of Dallas, Texas, has published the follow- 
ing interesting case, showing the benefit from stimulating and irritant appli- 
cations over the spine made in an unusual manner : A child aged three and a 
half years had been three weeks under treatment, through error of diagnosis, 
for supposed continued fever. When Dr. Sutton assumed charge of the 
case, November 20, 1877, the pupils were greatly dilated and insensible to 
light ; features pallid and pinched ; pulse 130 ; temperature 103° F. ; patient 
totally unconscious. November 21st, morning temperature 105°, pulse 140 ; 
evening temperature 101 i°, pulse 120. November 22d, morning temperature 
106 J, pulse 160; restless; evening temperature 105?°, pulse 120; had not 
slept, except for moments, for nearly two weeks. A strip of flannel saturated 
with turpentine was placed over the spine from the neck to the sacrum, and 



452 CONSTITUTIONAL DISEASES. 

a hot smoothing-iron was run up and down it, and eight drops of the fluid 
extract of ergot were given every three hours. Dr. Sutton adds : " The 
father stated to me that as soon as the application was finished the child fell 
asleep, and slept several hours — the first for two weeks — and the fever rapidly 
declined. From this time he began to improve, and gradually and fully recov- 
ered." The use of irritants and derivatives over the spine in the treatment 
of cerebro-spinal fever has been long and favorably known, but the mode 
of producing irritation in the above case was novel. 

Internal Treatment. — It will aid in the selection of the proper remedies to 
recall to mind the pathological state which we know to be present from the 
many autopsies which have been recorded. We have seen that the largest 
mortality, and consequently the most dangerous period, is in the first days, 
when there is intense, suddenly-developed inflammatory congestion of the 
meninges, with more or less secondary hyperseniia of the underlying brain 
and spinal cord, producing great headache, delirium, or somnolence, with 
exaggerated reflex irritability of the spinal cord, so that eclampsia is a com- 
mon and fatal complication. 

Fortunately, a remedy has been discovered in modern times (the bromide 
of potassium) which acts promptly and efficiently. It can be safely admin- 
istered in large and frequent doses to the youngest child. It is quickly elim- 
inated from the system through the kidneys and other emunctories in chil- 
dren, so as to prevent the occurrence of bromism, at least to the extent of 
causing any unpleasant consequences. It causes contraction of the minute 
vessels of the nervous centres so as to diminish the hypersemia, as shown by 
the experiments and observations of Dr. Putnam-Jacobi and others, and at 
the same time it diminishes, in a marked degree the reflex irritability of the 
spinal cord — two most beneficial and important effects of its use in this dis- 
ease. Many children by its timely employment are saved from the dangers 
of eclampsia, and by its sedative effect on the nervous system and contractile 
action on the capillaries it probably diminishes the intensity of the inflam- 
mation and the amount of exudation. I usually prescribe it, as recommended 
by Dr. Squibb, dissolved in simple cold water. In ordinary cases, not attended 
by eclampsia or marked symptoms which show that eclampsia is threatening, 
I generally prescribe at my first visit about four grains every two hours to a 
child of two years who has the usual restlessness and apparent headache, 
and six grains to a child of five years. If eclampsia occur, the bromide 
should be given more frequently, as every five or ten minutes, till it ceases. 
It is important to be able to determine when the quantity of the bromide 
administered should be diminished and when its use should be discontinued. 
I have very rarely observed bromism in children, and never to the extent of 
doing any serious harm, though for many years I have administered it in 
large and frequent doses whenever the occasion seemed to require it ; but 
the symptoms of bromism cannot readily be discriminated from those which 
may result from cerebro-spinal fever, such as muscular weakness, dilated 
pupils, with perhaps impaired vision, unsteady gait, nausea or vomiting, and 
abdominal pains. If the case progress favorably, frequent and large doses 
should, in my opinion, be given only in the first week, after which this agent 
should be given at longer intervals or in smaller doses. But during exacer- 
bations, which are liable to occur from time to time till the patient is well on 
the way to recovery, the use of the bromide in full doses is again indicated 
till the urgent symptoms begin to abate. 

Phenacetin is one of the most important, perhaps the most important, of 
the remedies for the early stages of the disease. I know no remedy which 
controls the headache and the fever more effectually than this, and without 
any detriment. Yet I prescribe it very sparingly, or not at all, after the first 



CEREBROSPINAL FEVER. 453 

week or ten days, through fear of its depressing effect. I always prescribe 
it with caffeine, which being a cerebral excitant, counteracts the depressing- 
effects of the phenacetine. The following is the formula which I employ 
for the adult : 

R. 01. cinnamomi, gtt. x ; 

Phenacetina?, h)iv (gr. 80) ; 

Sodii bromidi, £iij ; 

Caffeina? alkaloid, gr. xx ; 

Sacch. lactis, 3J. — Misce. 

Divid. in chart No. x. Give to an adult one powder every four to six hours 
according to the headache and fever. To a child of twelve years, half a pow- 
der ; to a child of eight years, one-third of a powder. 

Recently the pharmacists of New York City have in stock a coated pill con- 
taining 3 grains of phenacetine and 1? grains of citrate of caffeine. A half 
of one of these pills can be given to a child of twelve years, and one-fourth 
of one to a child of six years. 

Ergot is another remedy, but I am not aware that I have observed any 
benefit from its use in this disease. Its effect is, I think, mostly on the lower 
part of the spinal system. If employed it should be given during the first 
and second weeks, when the congestion of the nervous centres is greatest. 
At a more advanced stage, when there is less congestion and the danger 
arises from the inflammatory products and structural changes, the time for 
the use of ergot is past, or if it is still of some service it is less needed than 
at first and should be given less frequently. 

The severe headache and restlessness which attend many cases require 
the occasional use of an opiate or the hydrate of chloral. Chloral in proper 
dose never fails to give quiet sleep, and it is supposed by some who have 
studied its therapeutic action that it diminishes the cerebral circulation. It 
is therefore a useful adjuvant to the bromide. Five grains usually suffice 
for a child of six to eight years. Chloral is especially useful in cases 
attended by eclampsia or by symptoms which threaten eclampsia, since it acts 
promptly and decidedly in diminishing reflex irritability. Formerly it was 
considered injudicious and unsafe to prescribe opiates in meningeal inflamma- 
tion, since it was supposed that they increased the liability to coma, but 
experience shows that they are sometimes very useful in this disease when 
administered in small or moderate doses, and without the risk which was once 
supposed to be incurred by their use. The thirty-second part of a grain of 
morphia administered at intervals of some hours was sufficient to relieve the 
suffering of one of my patients at the age of six years. 

Quinia apparently does not exert any marked controlling effect on the 
course of cerebro-spinal fever or its symptoms, although the paroxysmal cha- 
racter of the severe pains in many patients suggests the use of this agent as 
an antiperiodic. It was frequently prescribed by New York physicians in 
the epidemic of 1872, but I believe that the opinion was unanimous that it 
was not the proper remedy. I have prescribed it in large and small doses, in 
one instance giving fifteen grains to a child of thirteen years, but do not know 
that I have observed any benefit from its use in this malady. It may increase 
the hyperaemia of the meninges and the cerebro-spinal axis. 

When the acute stage has abated measures designed to remove the serum 
which sometimes remains, constituting a hydrocephalus, are indicated. For 
this purpose the iodide of potassium is probably more useful than any other 
agent. It is administered by some physicians early along with the bromide. 
in the same manner in which they have been in the habit of treating other 
forms of meningitis. I have prescribed it with the bromide and alone when 
the bromide was discontinued, but whether it produces any marked sorbefa- 



454 CONSTITUTIONAL DISEASES. 

cient effect in this disease apart from the removal of serum seems to me 
doubtful. 

The result depends to a great extent on the nursing. The skill of the 
physician may be thwarted and the life of the patient lost by inefficient 
nursing. No other disease more urgently requires kind, intelligent, and con- 
stant attendance night and day on the part of the nurse. Not only should 
the medicines and nutriment be given punctually and regularly, but the 
great restlessness of the patient in the first days requires constant readjusting 
of the ice-bags, and during the long period of convalescence the utmost care 
is required to remove at once the excretions in order to prevent bed-sores, 
and to give the proper amount and kind of nutriment to prevent the emacia- 
tion and weakness from which many perish. 

The diet, from the beginning to the end of the malady, should be the 
most nutritious and such as is easily digested. It is necessary to give it in 
the liquid form, unless in mild cases in which the appetite may not be entirely 
lost. It is proper to aid the digestion by pepsin preparations. Nutritive 
enemata, consisting of beef tea or one of the extracts of beef, milk, and 
brandy, aid in averting the fatal prostration in protracted cases. After the 
acute stage has passed and the meningeal hyperemia has abated the alcoholic 
compounds in moderate doses, which in the beginning might be injurious, 
may now be useful, administered regularly by the mouth. The room should 
be dark, well ventilated, and quiet. All sympathizing friends who are not 
required in the nursing should be excluded. I know of no other disease in 
which this is so necessary, for mental excitement may produce dangerous 
aggravation of symptoms. 

We will close our remarks on this interesting disease by the report of a 
case from the pen of Dr. Augustus Caille, professor of the Post-Graduate 
Hospital, and one of the best clinical observers of New York : 

" C. V., a girl of German parentage, four years of age, was admitted to 
the Babies' wards January 29, 1894. She had become acutely ill four 
days previously, complaining of pain in the head, which was followed by 
vomiting and restlessness. When admitted to the hospital she was in a 
greatly emaciated state, with the head retracted. A diagnosis of cerebro- 
spinal meningitis was at once made, and the administration of mercury, 
quinia, and salicylate of sodium was contemplated in the order named, with 
the hope of counteracting with a few " specific " drugs the infection, the 
nature of which is still unknown. Calomel was given in one-quarter grain 
doses every three hours for two days. On the third and fourth days several 
five-grain doses of sulphate of quinine were administered in compound elixir 
of taraxacum and subsequently sodium salicylate, five grains four times a 
day in a watery solution, was given by mouth. An ice-cap was placed to 
the head, and a liquid diet was ordered. Constipation, a prominent symp- 
tom throughout the case, was overcome by means of compound licorice 
powder. The temperature was, as usual, very irregular, ranging from 101° 
to 105° F. 

" On February 8th the salicylate was discontinued and five grains of 
phenacetine were given night and morning, and a pepsin and hydrochloric- 
acid mixture was given several times during the day to aid digestion. From 
February 14th to 18th no medicine was given on account of vomiting. The 
child about this time remained for hours in complete opisthotonos. Hyper- 
esthesia was a prominent feature throughout the case, and contractures of 
different groups of muscles were noticed, usually with an elevation of tem- 
perature, but no eclamptic attacks. Oscillations of the pupils were noticed. 
The urine was free from abnormal constituents. 

" About February 20th a slight purulent discharge from the ear was 



ACUTE RHEUMATISM. 455 

observed, and a few days later divergent squint. In the later stage of the 
disease warm baths were given daily, and bromide of potassium internally, 
together with a nutritious and easily digested diet. On March 10th the 
child was out of bed and able to move about, and in a few days it will be 
sent to its parents, presenting no evidence of the recent severe illness 
through which it has passed."' 



CHAPTER V. 

ACUTE RHEUMATISM. 

Rheumatism is a constitutional disease with a local manifestation — to 
wit, inflammation of the fibrous tissues, chiefly in and around the articula- 
tions, but occasionally in other parts, as the heart and nervous centres. It 
was formerly supposed to be rare in children, but more accurate observations 
show that it is scarcely less common during childhood than in adult life. In 
young patients, especially under the age of six or eight years, it is frequently 
overlooked, for the articular inflammations in such patients are commonly 
slight. In the last twenty-five years, during my connection with the chil- 
dren's class in the Bureau for the Relief of the Out-door Poor, I have exam- 
ined many children with rheumatism or the cardiac lesions resulting from 
rheumatism, and ordinarily I have found that few joints had been affected, 
and that there had been but little swelling of them or redness, and that the 
patients were usually not confined to bed, or even to the sitting posture, but 
had been able to walk about, though with restraint and complaint of pain or 
soreness. The parents in many instances supposed that their children were 
suffering from "growing pains," as they designated them. At the same 
time, with this mildness of symptoms the heart was becoming seriously and 
permanently crippled by endocarditis. Those who have attended my clinics 
will recollect that on some days as many as three or four children with 
cardiac lesions have been present whose histories show an overlooked rheu- 
matism of this mild type. Cases like the following are very common among 
the city poor : 

In January, 1871, a little girl three years old was presented, having dis- 
tinct aortic direct and mitral regurgitant murmurs. The mother was not 
aware that she had had rheumatism, but at the age of twenty months she 
had for several days pretty active febrile symptoms, which the physician 
attributed to some other ailment. In April, 1871, another girl, of the same age, 
was brought to the clinic, having a distinct mitral regurgitant murmur. The 
mother stated that she had been well till a month previously, when she was 
confined to her bed for a few days, having a high fever. She was attended by 
a homoeopathic physician, and the exact character of her sickness the mother 
was not able to state. Further medical advice was sought, as the child 
remained delicate, though her health was better than at first. There can be 
little doubt that the obscure fever in this case was rheumatic. In another 
child treated elsewhere, not old enough to relate the subjective symptoms, 
there was, in addition to an intense fever, evident pain in one foot or leg 
when the limb was moved. Still, the nature of the disease was not diagnos- 
ticated till some time after recovery, when a valvular murmur was acci- 
dentally discovered. Such histories, which are not rare, show that rheu- 
matism often occurs in young children, even infants, and they inculcate the 



456 CONSTITUTIONAL DISEASES. 

important practical lesson that the disease at this age may be so obscure or 
latent as to be overlooked even by good diagnosticians. 

Some observers, meeting cases of valvular disease in children without the 
history of rheumatism, have concluded that rheumatism is not the chief cause 
of endocarditis at this age ; l but the explanation which I have given seems 
to me more in consonance with the facts. Scarlet fever not infrequently 
causes endocarditis, but this exanthem seldom occurs without detection, and 
it has been as often absent as has rheumatism from the histories as given by 
the parents of young children with valvular disease whom I have examined. 
Moreover, the endocarditis of scarlet fever is in many cases associated with, 
if it do not result from, scarlatinous rheumatism. 

Rheumatism in children is primary or secondary. The secondary form 
occurs chiefly in the declining stage of scarlet fever and variola. It is stated 
also to occur occasionally in new-born infants during epidemics of puerperal 
fever, but I have not observed such cases. 

Causes. — An inherited rheumatic diathesis is universally recognized as 
an important predisposing cause of this disease, so that it frequently occurs 
in different members of the same family. When the family history shows a 
strong predisposition to rheumatism, it occurs in the child from a slight 
exciting cause ; if no such predisposition exist, it only occurs through 
unusual circumstances of exposure. Investigations have been made in order 
to determine whether acute rheumatism is a microbic disease. Dr. Alfred 
Mantle of England made cultures from the serum of 7 and from the blood 
of 16 patients with acute rheumatism. He states that he made use of every 
precaution to prevent contamination by germs from without. The organisms 
obtained by Mantle in the cultures were a micrococcus and a small bacillus. 
He states that these organisms produced lactic-acid fermentation in sterilized 
milk. He believes that the microbes do not produce the symptoms of rheu- 
matism by their direct action, but by the ptomaines to which they give rise, 
and he raises the question whether lactic acid is not the chief ptomaine 
{Brit. Med. Jour., 1887). Popow states that the micrococci obtained by cul- 
tivation from the blood of rheumatic patients inoculated in rabbits caused 
in these animals the characteristic symptoms of rheumatism, and in their blood 
and synovial fluid he found the same cocci ( Wiener med. Presse, Jan. 29, 1888). 
Cornil and Babes have also related a fatal case of rheumatism in which mi- 
crococci and bacilli were found in the right knee. Wilson found bacilli in the 
pericardium* in two cases of rheumatic pericarditis. Petrone examined the 
serum taken from the knee-joint in three cases of acute rheumatism, and 
in all the specimens examined discovered microbes similar to those detected 
by Klebs in rheumatic endocarditis. Jaccoud relates the histories of two 
newly-born infants whose mothers at the time of their birth had acute rheu- 
matism. One of them twelve hours after birth, and the other three days 
after birth, ' ; were attacked with fever, rapid pulse, and well-marked rheu- 
matic swelling of several articulations." Under treatment one recovered 
in eight days and the other in a little more than two weeks. The above 
observations lend support to the theory that acute rheumatism is a micro- 
bic disease, and perhaps observations indicate that it is to a certain extent 
infectious. 

Children who have had one attack are especially liable to another, and 
when the diathesis is acquired slight exposures appear to be sufficient to cause 
the disease. It has heretofore been the common belief in the profession — and 
this opinion is also held by the laity — that exposure to cold is the usual excit- 
ing cause of rheumatism ; but if the disease have a microbic origin, it is a 
question whether or to what extent this theory is true. It is stated in support 
1 Dr. A. Steffen, Jahrbuchfur Kinderh., 1870. 



ACUTE RHEUMATISM. 457 

of it that rheumatism is most common in cold and changeable weather and in 
those who are most exposed to vicissitudes of temperature. 

Scarlatinous rheumatism has been alluded to above. Frequently during 
the course of scarlet fever inflammation of certain joints occurs which can- 
not be distinguished from that in the ordinary form of rheumatism, and in 
some of these instances endocarditis or pericarditis also occurs. Dr. Ashby 
is inclined to believe that scarlatinous rheumatism is produced by septic 
poisoning, but it sometimes occurs at such an early stage or in cases of such 
mildness that the conditions giving rise to ordinary sepsis do not seem to be 
present. It is therefore probable, in my opinion, that in some instances at least 
this articular affection occurring in scarlet fever is due to the direct action of 
the scarlatinous microbe or to a ptomaine or ptomaines produced by this 
microbe. 

Symptoms. — The commencement of acute idiopathic rheumatism is in 
most cases sudden ; occasionally fever and a degree of soreness or stiffness 
precede the articular affection for a few hours or days. The inflammation, 
slight at first, increases gradually, attaining its maximum intensity within one 
or two days. The joint is painful, red, hot, and swollen. The swelling is due 
to inflammatory oedema of the tissues surrounding the joint and effusion within 
the joint. As in all inflammations, the vascularity of the parts involved is 
increased, the synovial membrane loses, more or less, its lustre, and the effused 
fluid, which is mainly serum, has been found, in most of the cases in which 
an opportunity was presented for examining it, to contain a few leucocytes. 
Rarely fibrin is exuded, producing a rubbing sensation when the joint is moved, 
and perhaps impairing the mobility of the articular surfaces. Fortunately, 
however, in a large majority of cases the substance exuded both without and 
within the joint is mainly serum, and hence the rapid subsidence of the swell- 
ing when the inflammation ceases. The pain is commonly not severe when 
the child is quiet, but it is greatly increased if the joint be pressed or the 
limb moved. 

The joints of the extremities are most frequently the seat of rheumatic 
inflammation, but occasionally those of the trunk, as the intervertebral, the 
symphysis pubis, etc., are involved. As the inflammation abates in the artic- 
ulations first affected it reappears in others, unless the materies morbi have 
been eliminated from the system. It is seldom that more than two or three 
of the joints are in a state of active inflammation at the same time. 

The temperature in acute rheumatism is elevated two or three degrees 
above that of health, and the pulse varies from 120 to 140, its frequency de- 
pending on the age of the patient as well as the gravity of the disease. Per- 
spiration is a common symptom. The appetite is impaired, the tongue slightly 
coated, and the bowels constipated. The watery element of the urine is 
diminished, as in most febrile diseases, and there is not a corresponding reduc- 
tion in the solid elements, so that the urine is rendered more dense and its 
specific gravity is high. The amount of urea and coloring matter excreted 
from the kidneys is augmented during the active period of rheumatism, and 
the urine when it cools deposits urates. In ordinary cases there is no prom- 
inent symptom referable to the nervous system, with the exception of pain in 
the affected joint. 

Acute rheumatism, if only the articulations were involved, would be a dis- 
ease of little danger, however painful, but unfortunately in its proneness to 
produce specific inflammation of the sero-fibrous tissues the heart frequently 
becomes involved, less frequently the lungs and pleura, and in rare instances 
the cerebral or spinal meninges. The so-called cerebral rheumatism is attended 
by high fever, restlessness, headache, and sometimes delirium and coma. 
Twitching of the muscles and sometimes tonic or clonic spasms occur. Prof. 



458 CONSTITUTIONAL DISEASES. 

Flint says : " In the majority of cases death takes place during coma. In 
some cases recovery sets in even after the appearance of very grave symptoms. 
In fatal cases no lesions of the brain or of the meninges can really be found. 
The symptoms seem to be referable to some profound infection or intoxication 
which acts upon the thermic and other nervous centres." This form of rheu- 
matism is certainly rare in childhood. Endocarditis is the most frequent of 
the heart inflammations occurring in rheumatism ; pericarditis, though less 
common, is not infrequent ; while in rare instances myocarditis occurs, usually 
associated with the other inflammations. Endocarditis is limited to the left 
side of the heart, and seldom continues long without engaging the valves, 
aortic or mitral, or both, causing their infiltration, fibroid degeneration, with 
consequent thickening, and sometimes adhesion. The valvular lesion thus 
produced is in most instances permanent, so impairing the action of the valves 
as to obstruct in greater or less degree the flow of blood through the orifice 
and allow its regurgitation. 

The mitral valve is more frequently affected than the aortic ; at least bruits 
produced by this lesion are more frequently in the mitral than aortic orifice, 
and when they are heard in both orifices they are commonly loudest in the 
mitral. This fact, noticed by different observers, I have repeatedly verified 
by observations in this city. 

I have preserved the records of 73 cases of valvular disease in children, 
and in most of them I was able to assign rheumatism as the cause, but it was 
in a large proportion of instances very slight, so as not to confine the patients 
to bed, and had been considered by the parents simply " growing pains," so 
that no treatment had been received. The statistics of different observers 
show that endocarditis in acute rheumatism occurs more frequently in chil- 
dren than in adults. The first sign of an endocardial inflammation is in 
most instances a systolic murmur produced in the mitral orifice. It can be 
heard on listening over the heart, and also over the left scapula. It indi- 
cates insufficiency of the mitral orifice and regurgitation of blood into the 
left auricle. In some cases the aortic valves are at the same time affected, 
and an aortic direct murmur occurs, synchronous with the mitral regurgi- 
tant. In rare instances the endocarditis extends to the aortic orifice, causing 
thickening of its valves and impairing their action, so that an aortic bruit 
results, while the mitral orifice is not affected, and therefore no mitral 
murmur occurs. 

Another cardiac bruit resulting from the endocarditis occasionally observed 
is a reduplication of the second sound, heard most distinctly at the apex. A 
diastolic sound sometimes follows this reduplication, and when it is well 
developed it constitutes the so-called presystolic murmur. It usually results 
from mitral stenosis caused by the endocarditis. 

Pericarditis is not so common in rheumatism as endocarditis, but it some- 
times occurs in children as well as in adults. It occasionally even precedes 
the affection of the joints, being the first in time of the rheumatic inflam- 
mations. It causes an increase in the fever, palpitation, quick and irregular 
pulse, restlessness, cardiac pain, and perhaps dyspnoea. At first a pericardial 
friction-sound may be detected, and subsequently, when sero-fibrinous exuda- 
tion has occurred, the area of dulness may be increased, with a muffling of 
the sounds of the heart. If the effusion of serum be moderate, the peri- 
cardial surfaces may become agglutinated early in the disease, or they may 
become agglutinated after the serum is absorbed, so as to prevent friction- 
sound. An adherent pericardium embarrasses the action of the heart, and 
is likely to lead eventually to hypertrophy. Tonsillitis occurs so frequently 
in children who have the rheumatic diathesis, and also so frequently during 
rheumatism, that Trousseau recognized a rheumatic form of the disease. 



ACUTE RHEUMATISM. 



459 



Bronchitis, pleurisy, and pneumonia also occasionally occur as complications 
of rheumatism. 

While the articular affections pertain to the clinical history of rheuma- 
tism, the internal inflammation, whether of the heart, lungs, pleura, or 
meninges, though similar as regards its pathological character, is properly 
considered as a complication. Acute rheumatism is so frequently complicated 
by one or the other of these affections that any disproportionate severity in 
the general symptoms, as compared with the inflammation of the joints, or 
any sudden and unexpected increase in the symptoms, should always lead 
the physician to examine thoroughly the condition of those organs which 
are most frequently affected. 

Inflammatory complications occur, as a rule, during the active period 
of rheumatism, when the inflammation is passing from joint to joint. If the 
general symptoms begin to improve and no new joints are involved, the lia- 
bility to complications is greatly diminished. 

Pathology. — The joints affected by rheumatism present various grades 
of inflammation, but in all typical cases, however intense the inflammation, 
suppuration does not occur. In a paper read before the London Medical 
Society, April 9, 1888, Dr. Money stated that when suppuration does occur 
in rheumatism the disease is complicated with septicaemia, and Sir Wm. 
MacCprmac and Dr. Ord expressed a similar opinion. 

Acuteness of sensation is increased over the inflamed joint. The ana- 
tomical changes in the joints have been sufficiently described in our remarks 
relating to the symptoms. Recently several writers have called attention 
to the fact that nodules occasionally occur under the skin in rheumatism. 
Lindmann relates two cases, an adult and a child, in which during the course 
of rheumatism numerous nodules appeared rapidly under the skin. They 
were about the size of a pea, hard, movable, and painful, but without red- 
ness. They disappeared during convalescence. Lindmann collated the records 
of 59 rheumatic cases in which nodules occurred. A majority of them were 
females, and 46 were children. These bodies usually appeared suddenly in 
the later stages of rheumatism, and varied from the size of a pin's head to 
that of an almond. They continued from a few days to a month or longer 
(Deutsche med. Woch., p. 519, 1888). 
Examination with the microscope 
shows that they consist of newly- 
formed connective tissue, such as re- 
sults from inflammation (Amer. Journ. 
of Med. Sci., Oct., 1888). Garrod states 
that these nodules and muscular atro- 
phy sometimes occur in the most simple 
forms of hydrarthrosis, and are usually 
attended by an increase in the reflexes, 
suggesting an excitability in the spinal 
cord (Lond. Lane, June 2, 1888). It 
is stated that Charcot and Parisot also 
attribute the occurrence of these nod- 
ules to an exaggerated excitability 
of the spinal cord. On the other 
hand, Mayer and Cuilleret observed 
two cases of nodules and atrophy of 
certain muscles following an attack 
of arthritis, and they think that a true 
myelitis had occurred to produce such a result, along with the constant 
peripheral irritation {Lyon medical, Apr. 29, 1888). Homan relates the case 



Fig. 60. 




460 CONSTITUTIONAL DISEASES. 

of a patient aged eighteen years who had rheumatism of the muscles of the 
left leg from the hip to the ankle, lasting several weeks. In the latter part of 
his sickness the calf of the leg became unusually tender, and a hard nodule 
occurred in the muscular substance, and was accompanied by atrophy of 
the muscular fibres. The nodule gradually subsided and disappeared (St. 
Louis Courier of Med., March, 1888). The above observations, to which more 
might be added, show that the anatomical characters of acute rheumatism 
are not restricted to the joints and heart, but subcutaneous nodules, and more 
or less muscular atrophy, occasionally occur. Cheadle says the nodules occur 
mostly in the neighborhood of joints, and that they are rare in adults, but 
very common in children. They develop within a few days, and sometimes 
in successive crops, " but they usually take many weeks to subside." The 
above figure represents these nodules as seen by Dr. Cheadle in a boy of 
four years. 

Fig. 61. 



t- 












- -&H : . 






The woodcut (Fig. 61) shows the microscopic appearance of a nodule from a 
child of seven and a half years, as observed by Dr. Cheadle ; it exhibits the 
active cell-infiltration and proliferation of fibrous tissue. 

Duration ; Prognosis. — With proper treatment and without complica- 
tion the febrile action in a few days begins to abate, and the disease com- 
monly terminates within two weeks. Its duration is ordinarily shorter than 
in rheumatism of the adult. Fluctuations, however, are liable to occur. 
The disease may appear to be abating and the articular inflammations nearly 
cease when they return for a time, often without new exposure and without 
appreciable cause. The prognosis, even when cardiac inflammation has super- 
vened, is in most cases favorable, except so far as the lesion resulting from 
this inflammation is concerned, which being permanent may entail much sub- 
sequent suffering and occasion death after months or years. Indeed, what is 
most to be dreaded in cases of acute rheumatism is valvular disease or peri- 
cardial adhesion with its remoter consequences — namely, hypertrophy of 
heart, congestion and oedema of lungs, dropsies, etc. 

Secondary rheumatism occurring in scarlet fever is sometimes also com- 
plicated with, or rather coexists with, cardiac inflammation, pleuritis, or pneu- 
monitis, rendering the prognosis more unfavorable. 

In rare instances the acute symptoms of rheumatism abate, but the 
joints remain stiff and more or less swollen and painful when moved. The 



ACUTE RHEUMATISM. 



461 



acute has lapsed into a subacute or chronic rheumatism. Such a case, rep- 
resented in the accompanying figure (Fig. 62), was brought to the children's 
class in the Out-door Department at Belle vue Hos- 
pital in February. 1871. E.'H , a female three Fig. 62. 

and a half years old. had intermittent fever from 
the age of nine to fifteen months. From this time 
she remained well till the age of two years, when 
she was taken with acute rheumatism, commencing 
in her ankles and extending to other joints. The 
knee- and hip-joints on both sides have only par- 
tially recovered their mobility, and both legs and 
both thighs are permanently flexed, so that the 
gait is slow and unsteady. It is impossible to 
straighten either limb without causing great pain, 
and attempts to straighten the thigh produce the 
arch in the back very similar to that in coxalgia. 

Diagnosis. — This is not difficult in ordinary 
cases if a proper examination be made. In the 
commencement, if the affection of the joints be 
slight, rheumatism might be mistaken for remit- 
tent, typhoid, one of the eruptive fevers, or men- 
ingitis ; but on careful examination tenderness of 
one or more of the articulations will be observed, 
and probably some swelling. This tenderness is 
readily distinguished from the hyperesthesia which 
is common in the first stage of the essential fevers, 
and which is observed when pressure is made upon 
the chest or abdomen as well as upon the limbs, 
and is more marked between the joints than in 
them. Any doubt which may at first exist whether 
the patient may not have one of those diseases is 

soon dispelled, since their clinical history presents notable differences from 
that of rheumatism. 

I have known scrofulous arthritis or scrofulous osteitis near the joint 
present so close a resemblance to acute rheumatism as to be at first mistaken 
for it. In one instance this inflammation commenced nearly simultaneously 
in three joints, rendering the diagnosis at first very difficult. But scrofulous 
inflammation, as well as that from pyaemia, can be diagnosticated from rheu- 
matic disease of the joints by its greater persistence, less induration and sym- 
metry in the swelling, and by the history of the case. Chronic rheumatism 
may produce deformity similar to that from chronic scrofulous inflammation, 
as in the case mentioned above, but the rheumatic history, number of joints 
affected, bilateral character of the inflammation, good general health, etc. are 
sufficient to establish a clear diagnosis when the disease has been observed for 
some days. 

Treatment. — The treatment of acute rheumatism has undergone marked 
variations in the last thirty years. Its speedy cure is urgently demanded, on 
account of the imminent peril to the heart. From 1847 until a recent period 
the alkaline treatment, by the bicarbonate of potassium and bicarbonate of 
sodium, the tartrate of potassium and sodium, and the citrate of potassium, 
was commonly employed to the extent of rendering the urine alkaline in 
twelve or twenty-four hours. Statistics appeared to show that the duration 
of rheumatism was abridged by the alkaline treatment, and the liability to 
cardiac complications was diminished as soon as the urine became alkaline. 
Grarrod reported 50 cases in which the average duration was six or seven 




462 CONSTITUTIONAL DISEASES. 

days under the alkaline treatment. Fuller in 1862 stated that in no single 
instance in 194 cases did cardiac complications occur when the alkaline treat- 
ment had been employed twenty-four hours. Dickinson's statistics also fur- 
nished strong evidence of the usefulness of alkalies in large doses, given so as 
to render the urine alkaline in twelve to twenty-four hours. He also stated 
that the alkaline treatment was inadequate unless employed so as to render 
the urine alkaline. More recently, the late Prof. Austin Flint considered 
the evidence conclusive in regard to the efficacy of the alkaline treatment of 
rheumatism, the doses employed being so large that the urine becomes alka- 
line in twenty-four hours. 

But since 1875 a new and, in acute cases of rheumatism, a very efficient 
remedy has come into use — to wit, salicylic acid, or its compound, salicylate 
of sodium. The sodium salicylate is most frequently employed. It may be 
given every two hours to adults in doses of ten to twenty grains, and to 
children in proportionate doses. But, although salicylic acid or salicylate 
of sodium acts almost as a specific in recent cases of rheumatism, relieving 
the pain and fever and diminishing the articular inflammation, it often pro- 
duces certain ill effects. It impairs digestion, causing nausea, and sometimes 
vomiting. It produces tinnitus aurium, and sometimes headache or vertigo, 
and occasionally albuminuria, as I have several times observed, so that it 
should not be employed longer than is required to control the rheumatism. 
The employment of salicylic acid or salicylate of sodium does not, apparently, 
prevent cardiac or other complications, and it is probably best to administer 
it in combination with, or alternately with, an alkali. 

The following formula is essentially that which has been employed in the 
Out-door Department at Bellevue with apparently excellent results : 

R. A cidi salicylic, ^ij-iij ; 

Pot as. acetat., J§ss ; 

Glycerini, ^j ; 

Aqufe, q. s. ad J; v. — Misce. 

Give one teaspoonful every two or three hours to a child of six years. 

An eligible vehicle for the sodium salicylate is the syrup of raspberry, 
as in the following formula : 

R. Sodii salicylat., ^iij ; 

Sodii bicarbonat, ,^ij ; ' 

Syr. rubi idsei, ^ij ; 

Aqure, 3 iij . — Misce. 

Give one teaspoonful every two or three hours to a child of six years. 

Since the oil of wintergreen contains a considerable amount of salicylic 
acid, it has been sometimes employed, as in the following formula: 

R. 01. gaultherise, 3J ; 

Sodii salicylat., ^iij ; 

Syr. simplic, J^iij ; 

Aqusp, ^vj. — Misce. 

Dose : A dessertspoonful to a child of five years. 

During the declining period of rheumatism and in convalescence quinine 
or some preparation of cinchona should be employed and the above medicine 
given less often. This tonic does indeed appear to exert a beneficial effect on 
the course of rheumatism, and is employed by some judicious and experienced 
physicians from the commencement. 

If there be a high temperature and a quick pulse, quinine administered in 



ERYSIPELAS. 463 

an occasional large dose will be found very useful. Three to five grains may 
be given to a child of five years. 

Rheumatism impoverishes the blood, and the patient often begins to present 
an anaemic appearance, when he requires iron in addition to the vegetable 
tonic. The citrate of iron and quinine may then be employed. 

Secondary rheumatism requires sustaining treatment from the first. Such 
cases ordinarily do well without antirheumatic treatment, with the general 
supporting measures employed for the primary disease. 

Pneumonitis complicating rheumatism is best treated by moderate coun- 
ter-irritation and emollient poultices and the internal use of carbonate of am- 
monium or quinine. In pericarditis or endocarditis if, as is commonly the 
case, the movements of the heart be accelerated, aconite or the tincture or 
infusion of digitalis is demanded to the extent of reducing the number of 
pulsations to near the normal frequency. A child of six years can take three 
drops of the tincture or a large teaspoonful of the infusion, to be repeated, 
if necessary, in three hours till the reduction of the pulse is effected. Pa- 
tients often experience relief by the use of this agent from the palpitation 
and dyspnoea consequent upon the embarrassed movements of the heart. If 
the heart disease be severe and pulse feeble, quinine is also useful. The tinc- 
ture of strophanthus or that of spartein is sometimes prescribed as a substi- 
tute for the digitalis. 

The patient should be kept quiet in a room of uniform temperature, and 
not exposed to draughts of air. By such precautions the danger of compli- 
cations is greatly diminished. Repellant applications, as cold or irritants, 
should not be applied to the joints so long as the disease is acute, for they also 
increase the danger of complications. The affected joints should be envel- 
oped in flannel or cotton, and the pain, if intense, may be diminished by apply- 
ing flannel wrung out of warm water. If the disease become subacute or 
chronic, if the urates have disappeared from the urine, and the inflammation 
cease to pass from joint to joint, the tincture of iodine or moderately stimu- 
lating embrocations applied to the joints involve no danger and are useful. 



CHAPTER VI. 

ERYSIPELAS. 

The term " erysipelas " is applied to a constitutional or blood disease which 
is characterized by inflammation of the skin and subcutaneous connective 
tissue and a tendency to spread. It is accompanied by pungent and pricking 
heat, swelling, and subcutaneous infiltration. 

It involves especially the lymph vessels and spaces. The skin has a bright- 
red color and is swollen. 

Erysipelas occasionally occurs in childhood ; the cases which are met in 
this period present nearly the same features and pursue nearly the same course 
as in the adult. In infancy erysipelas is a common disease, and the following 
remarks relate chiefly to erysipelas occurring in this period of life. My sta- 
tistics are based on data derived mainly from the records of cases which oc- 
curred in this city, some in my own practice, and others in the practice of 
physicians known to be good observers. The points of chief interest in 41 
cases are embraced in the following table. In addition to these cases, I have 
records of some which are designated septicaemia in which more or less 
erysipelas occurred at and extended from the umbilicus. 



464 



CONSTITUTIONAL DISEASES. 



Cases of Infantile Erysipelas. 







Age. 


Point of 
commencement. 


Parts affected. 


Duration. 


Result. 


1 


M. 


o months. 


Right knee. 


i 
Entire surface, except face and scalp. 5 weeks and 

1 3 days. 
From a little above the knee to the 7 days. 


Recovered. 


2 


M. 


2 years. 


Left knee. 


Recovered. 


3 


M. 


10 months 


Elbow. 


Whole arm and forearm. 




Recovered. 


4 


F. 


20 


Below right knee. 


Entire leg, thigh, and trunk to the 
umbilicus. 


7 days.. 


Recovered. 


5 


F. 


9 


Vulva. 


Abdomen, chest, and all the ex- 
tremities. 


18 " 


Recovered. 


6 


M. 


9 days. 


Genitals. 


Both lower extremities, abdomen to 
the umbilicus. 


6 " 


Died. 


7 


F. 


1 year. 


Vulva. 


Entire surface, except face. 


6 weeks. 


Recovered. 


8 


F. 


6 weeks. 


At or near the ear. 


Forehead and side of face. 1 week. 


Died in tetanic 


9 




9 months. 


Epigastric region. 


Trunk and lower extremities. 2 weeks. 


spasms. 
Died in tetanic 
spasms. 


10 


F. 


10 


At angle of mouth. 


Entire face and scalp. 10 days. 


Recovered. 


11 


F. 


4 weeks. 


Vulva. 


Entire surface, except face. 3 weeks. 


Died. 


12 


F. 


3 months. 


Vulva. 


Surface of abdomen to umbilicus and 2 " 
right lower extremity. 


Recovered. 


13 


F. 


4 to 5 mos. 


Vulva. 


All the limbs and trunk, except the 3 to 4 weeks. 

chest. 
Trunk and both lower extremities. 


Died. 


14 


F. 


5 months. 


From syphilitic 










sores around anus. 






15 


F. 


3 


Vulva. 


Entire trunk and both upper ex- 3 weeks, 
tremities. 


Recovered. 


16 


M. 


8 


Face near nostrils. 


Entire trunk and both upper ex- About 2 
tremities. 1 weeks. 


Recovered. 


17 


F. 


4 


Vulva. 


Entire trunk and all the extremities. 1 week. 


Died. 


18 


F. 


7 


Knee. 


A portion of trunk and both lower 3 weeks, 
extremities. 


Recovered. 


19 


F. 


6 


Near the ear. 


Entire face and forehead. 10 days. 


Recovered. 


20 


M. 


7 davs. 


Left eyelid. 


Left side of face. 


3 " 


Died. 


21 


M. 


14 " 


Genitals. 


Extended to knee, over abdomen to 
the chest. 


4 " 


Died. 


22 


M. 


3 months. 


Under the chin. 


Chin, left cheek, neck, left side of 
trunk, left thigh and leg. 






23 


F. 


28 


Right shoulder. 


Arm and forearm. 


lday. 


Died in con- 
vulsions. 


24 


F. 


3 or 4 days. 


Vulva. 


Body and all the limbs. 


12 days.' 


Died. 


25 


F. 


3^ mos. 


Under left ear. 


Neck, chest, and arms. 


About 2 
weeks. 


Died. 


26 




7 months. 


Below right knee. 


Trunk, neck, and head, and all the 

limbs. 
Both thighs and nearly entire trunk. 


2 weeks. 


Died comatose. 


27 


F. 


6 


Vulva. 


3 days. 


Died comatose. 


28 


M. 


19 


Near point of 
vaccination. 


Shoulder, arm, and forearm. 


21 " 


Recovered. 


29 


M. 


4 « 


Near point of 
vaccination. 


Chest and both upper limbs. 2 weeks. 


Recovered. 


30 


M. 


2 " 


Near vaccine 
vesicle. 


Trunk and all the limbs. |l0days. 

| 


Died. 


31 




3 to 4 mos 


Near vaccine 


Arm, forearm, and shoulder on one 2 to 3 weeks. 


Died. 








vesicle. 


side. 






32 


F. 


4 months. 


Near vaccine 
vesicle. 


Arm, forearm, and trunk. 


2 months. 


Died. 


33 


M. 


2 


Near vaccine 
vesicle. 


Nearly entire surface. 


1 week. 


Died with per- 
itonitis. 


34 


M. 


5^ " 


Near point of 
vaccination. 


Arm and forearm. 




Recovered. 


' 


M. 


2K " 


Near point of 
vaccination. 


Arm. 


7 days. 


Died probably 
of peritonitis. 


36 


M. 


8 


Near vaccine 
vesicle. 


Arm and forearm. 


17 " 


Died. 


37 




5 


Left foot. 


Leg, thigh, and lower part of trunk. 


2 weeks. 


Died witb 
pneumonitis. 


38 




5 weeks. 


At one ear. 


Entire surface. 


2 " 


Recovered. 


39 




2 months 


Left leg. 


Trunk and all the limbs. 


2 " 


Recovered. 


4(1 




4 


Near point of 
vaccination. 


Trunk and all the limbs. 


2 " 


Died. 


41 


M. 


14 


Face. 


Trunk and all the limbs. 4 " 


Recovered. 



Age. — Of the above cases, 27 were under the age of six months, 9 from 
six months to twelve, and only 5 above the latter age. A large majority, 
therefore, of cases of infantile erysipelas occur in the first year of life. 

Point of Commencement. — In 58 cases in which I have ascertained 
the point of commencement it was in 13 cases the vulva, 17 the arm after 



EBYSIPELAS. 465 

vaccination, 7 the leg. 6 the face, 3 the male genital organs, 3 at or near the 
ear. 1 the elbow. 1 the shoulder. 1 the nates, 1 the foot. In the adult, idio- 
pathic erysipelas commonly commences upon the face and affects only the 
face, ears, forehead, and scalp. On the other hand, in infantile erysipelas 
statistics show that the rash commences upon the face only in a small pro- 
portion of cases. 1 in 9, and that it rarely extends to the face when it com- 
mences in other parts. 

Causes. — The fact that erysipelas is infectious has led to many micro- 
scopic examinations in order to discover the nature of the microbe which 
causes it. In most instances some injury of the surface has occurred through 
which the poison is received — a scratch or abrasion or a slight cutaneous 
eruption. Many cases have been cited showing infectiousness. In my 
practice a child contracted it from lying in bed with one of the family who 
had facial erysipelas. The following cases were related before the Paris 
Academy in 1864 : Dr. Paintevin contracted erysipelas from two cases occur- 
ring in a hospital ward, and was visited by Dr. Testart of Gruise, a place free 
from ervsipelas. Three days after returning home this physician sickened 
with erysipelas. His servant, who waited on him, and a relative living 
twenty-four miles away, who called on him. also contracted the disease. The 
relative's wife was then seized with it, and also three members of a family 
who had called upon them. These last patients communicated the disease 
to a relative and two Sisters of Mercy who nursed them. These sisters, 
returning to the convent, infected others, among whom was the physician of 
the convent, who died. The physician's daughter also contracted it, the 
inflammation beginning in leech-bites which had been made over enlarged 
glands. Infectiousness has been shown not only by clinical experience, but 
also by experiments ; small tumors have been successfully inoculated with 
cultures of the erysipelatous cocci, but some of the patients thus treated 
have died. The attempt to remove tumors by inoculating them with the 
erysipelatous virus shows the highly infectious character of erysipelas, and 
certain small tumors have been removed by the erysipelas, while in other 
instances the result has been disastrous, death occurring. 

Fehleisen has discovered the specific microbe of erysipelas — to wit, a 
chain coccus designated the streptococcus erysipelatis. This streptococcus 
has been designated streptococcus erysipelatis, which he has cultivated, and 
by inoculating the cultures he has been able to reproduce erysipelas in 
tumors. More recently Meerovitch made microscopic examinations in 
thirty-one cases of erysipelas, and invariably found a large number of these 
streptococci in the affected skin, and in grave cases also a few in the blood. 
He detected this organism in abscesses and in fatal cases likewise in internal 
organs. The cultures made in meat bouillon preserved their vitality four or 
five months. It is now known that this organism sometimes passes from 
the maternal organism to the foetus through the uterine circulation. Ziegler 
says that the micrococcus which causes erysipelas enters the lymphatics and 
spreads chiefly by them. They are found, says he, in immense masses or 
swarms in the lymphatics, and from them they spread into the tissues, where 
they excite inflammation and often tissue-necrosis (Lond. Med. Recorder, 
Nov. 20, 1888). 

The blood may undergo certain changes which predispose to erysipelas or 
render the system less able to resist the micrococcus. Among the causes 
which produce this state of system, uncleanliness, residence in damp, dark, 
and crowded apartments, and defective alimentation hold a principal place. 
Hence this disease is more common in the poor quarters of a city than in 
the country, and in dispensary and hospital than in family practice. 

In a large proportion of cases there is an irritation or inflammation at 
30 



466 CONSTITUTIONAL DISEASES. 

some point, generally trivial, through which the streptococcus enters the 
system. Erysipelas therefore commonly begins at a simple ecthymatous or 
impetiginous eruption, around burns or suppurating sores or syphilitic erup- 
tions ; it frequently commences, as is seen by the above table, near the point 
of vaccination immediately after vaccination or when the pock is developed, 
or again when it has run its course and been detached. In erysipelas super- 
vening on vaccinia the streptococcus erysipelatis has probably been conveyed 
by dirty fingers or clothing. I might relate two instances in the practice of 
two physicians in which the old way of vaccinating with the scab produced 
severe erysipelas in children on whom it was used. The scabs probably con- 
tained the streptococcus erysipelatis. In a considerable proportion of cases 
it begins at the point where the skin is thin and delicate or where it unites 
with a mucous surface. Thus, I have records of cases in which it commenced 
at the external ear, commissure of the mouth, and at the vulva. Indeed, the 
frequency with which it commences at the vulva renders female infants more 
liable to it than males. In some instances erysipelas begins without any local 
exciting causes upon smooth and sound skin, even when there are sores upon 
various points of the surface. 

Erysipelas neonatorum is treated of in our remarks on Septicaemia of the 
New-born. 

Premonitory Symptoms. — Infantile erysipelas in certain cases has no 
premonitory stage, or, if present, it escapes notice. In other instances there 
are well-marked precursory symptoms, as drowsiness or restlessness, more or 
less fever, oppressed respiration, with perhaps vomiting and sudden twitch- 
ing of the limbs. In Cases 28 and 37 of the table, which occurred in my 
practice, the fever, restlessness, and dyspnoea were so great for three days 
before the appearance of the eruption as to cause much anxiety. In the 
adult erysipelatous patient pharyngitis often precedes the occurrence of the 
rash upon the skin. The same inflammation may be present in the premon- 
itory period of infantile erysipelas, as well as during the period of erysipe- 
latous eruption. The hurried and difficult respiration which is present in the 
commencement of some cases is probably due to an erysipelatous turgescence 
of the bronchial mucous membrane. 

Symptoms. — The patient with this disease is usually restless in conse- 
quence of the burning pain which accompanies the eruption. In severe cases 
there is little sleep, night or day, except from medicine. The sleep is short, 
and is often interrupted by sudden starting or twitching of the limbs. Con- 
vulsions may occur, but are not common. 

Fever is constantly present, and is proportionate to the extent and gravity 
of the erysipelas. I have notes of cases in which the pulse was more than 
200 per minute, although other symptoms did not indicate immediate danger. 
The skin not affected by erysipelas is dry and hot, though not possessing the 
pungent heat of the inflamed portion ; face often flushed ; tongue moist and 
covered with a light fur ; stomach usually retentive. The state of the bowels 
varies : sometimes they are regular, sometimes variable, and in other cases 
the stools are green and more frequent than natural. I have records relating 
to the state of the bowels in 20 cases, as follows : In 7, regular ; in 9, loose ; 
in 2, constipated; in 1, constipated, then loose; and in 1, constipated, then 
regular. Diarrhoea, when present, is usually mild, requiring little or no treat- 
ment. The erysipelatous redness is not in all cases so pronounced as in the 
adult, but otherwise there is nothing peculiar in its appearance. In feeble 
infants with an impoverished state of the blood its color is pink, instead of 
the deep red which characterizes the inflammation in the robust. Points 
of vesication may occur where the inflammation is most severe, as in the 
adult, and subsequently the same desquamation and oedema. 



ERYSIPELAS. 467 

If the infant be debilitated, there is great danger of the formation of 
abscesses around which the inflammation lingers after it has disappeared 
from every other part of the body. Sometimes also in very young infants 
gangrene occurs, especially in the genital organs in the male. Several of 
these cases have been related to me, all under the age of a month or six 
weeks, and all fatal. Occasionally the sloughing is so great as to denude the 
testicle. A noteworthy feature of erysipelas in infants is its proneness to 
return. When it has been progressively subsiding and hope is entertained 
of its speedy disappearance, it not infrequently is suddenly relighted from 
some unknown cause, travelling again over the same or parts of the same 
surface. In one case the disease, arising from vaccination, extended three 
times over the arm and forearm ; and in another case a second time over 
both legs and a considerable part of the trunk. 

The internal inflammations which most frequently complicate erysipelas 
and give rise to symptoms which are superadded to those pertaining to the 
erysipelas are pharyngitis and peritonitis, and more rarely broncho-pneumonia 
or enteritis. In a case which I examined after death in the Nursery and 
Child's Hospital, and in which, the erysipelatous inflammation having 
extended over the abdomen, the lesions of peritonitis were present, it 
appeared from the thinness of the abdominal walls that the inflammation 
had extended through them from the external to the internal surface or from 
the skin to the peritoneum. 

Prognosis. — Erysipelas is much more fatal in infancy than in adult life. 
In the death-statistics of this city for three years I find 80 deaths from ery- 
sipelas of infants under the age of one year, to 83 deaths from this disease 
above that age. Age greatly influences the prognosis. Infants under the 
age of three weeks usually die ; from the age of three weeks to six months the 
result is doubtful ; while above the age of six months a majority recover with 
correct treatment. It will be seen by the foregoing table that 7 infants under 
the age of six weeks had erysipelas, and 6 died ; from the age of six weeks to 
six months, 6 recovered and 9 died; and above the age of six months, 9 recov- 
ered and 4 died. 

With the exception of a case of the so-called umbilical erysipelas, the 
youngest child who recovered of whom I have obtained information was three 
weeks old. In this case the rash extended nearly over the entire surface, be- 
ginning with the face. Case 38 of the table, treated by myself, was very 
similar as regards the extent of the erysipelatous eruption and the result. 
This infant was five weeks old. 

It is scarcely necessary to state that erysipelas is more favorable when it 
affects the limbs than when it invades the head, neck, or body ; when it spreads 
slowly than rapidly ; when it is superficial than when phlegmonous. In those 
cases in which the connective tissue is much involved the infant is not always 
safe after the disease has run its course ; he sometimes dies exhausted from 
the discharge of abscesses ; I have records of two such cases. 

Duration. — In 16 cases that recovered the erysipelas terminated within 
the first week in 2, the second week in 6, the third week in 5, fourth week in 
1, and in 2 cases it lasted five and six weeks. The average duration was fifteen 
days. In 19 fatal cases, 10 died within the first week, 5 the second week, 3 
the third week, and 1 in the fourth week. The average duration of fatal cases 
was about ten days. 

Modes of Death. — Death occurs in different ways : in chronic or tonic 
convulsions followed by coma, from exhaustion, and from internal inflamma- 
tion, that from exhaustion being probably the most common. 

Pathological Anatomy. — The blood doubtless in this disease under- 
goes certain pathological alterations previously to the occurrence of the erup- 



468 CONSTITUTIONAL DISEASES. 

tion, but the exact changes are not known. Our knowledge of the morbid 
anatomy of erysipelas relates chiefly to the local affections, which, with the 
exception of the inflammation of the skin, are not constant, and may there- 
fore be regarded as complications. The cutaneous inflammation affects all the 
structures of the skin, and in greater or less degree also the subcutaneous con- 
nective tissue. The inflammation is accompanied by more or less serous effusion 
or oedema. 

The not infrequent occurrence of peritonitis in connection with erysipelas 
has long been known. In Heberden's Epitome Morborum Puerilium the ana- 
tomical character of erysipelas is expressed in one sentence : " When the body 
has been opened after death the intestines have been found glued together and 
covered with coagulable lymph."' Since Herberden's time nearly all who have 
written on diseases of infancy and childhood have mentioned peritonitis as one 
of the most common complications of erysipelas. Underwood says: "Upon 
examining several bodies after death the contents of the body have frequently 
been found glued together and their surface covered with inflammatory exu- 
dation exactly similar to that of those who have died of puerperal fever." 
Similar remarks in reference to the frequency of peritonitis in this disease are 
made by recent writers. 

The statistics in reference to erysipelas as well as peritonitis show that in 
infants in hospital practice, and in those affected by erysipelas during epi- 
demics of puerperal fever, peritonitis is a not infrequent complication. On the 
other hand, as we commonly meet cases of infantile erysipelas occurring spo- 
radically in private practice, abdominal distention and tenderness are not suf- 
ficient to indicate peritonitis. In only one of the cases embraced in the fore- 
going table was a post-mortem examination made, and in that there had been 
no peritonitis. The occurrence of pharyngitis in connection with erysipelas has 
been already mentioned. 

Enteritis has been alluded to as another complication in infants. Diar- 
rhoea has been stated to be a symptom in certain cases, and it has been found 
to be dependent on enteritis of a mild grade. Billard made post-mortem exam- 
inations of 16 infants who died of erysipelas, and " found in 2 gastro-enteritis, 
in 10 enteritis, in 3 pneumonia complicated with enteritis and cerebral conges- 
tion, and in 1 pleuro-pneumonia." 

Prophylaxis. — A patient with erysipelas should be isolated, and the bed- 
ding and linen worn by him should be placed in boiling water as soon as re- 
moved. No one should be allowed to occupy the bed or room when vacated 
by the patient until it has been thoroughly disinfected. 

Treatment. — The external treatment has varied greatly, but those agents 
are now most employed which have soothing or antiseptic properties. Among 
them we may mention iodoform in collodion. Scarification and leeching, 
formerly employed, have been abandoned as pernicious, and astringents, as 
alum and sugar of lead, are now known to be inefficacious. 

I have obtained the best results by applying the following ointment over 
the inflamed surface every three or four hours : 

R. Ichthvol, 3j ; 

Ung. aquse rosse, Sjj. — Misce. 

On this side of the Atlantic great uniformity prevails as regards the in- 
ternal treatment of erysipelas. Sustaining measures are prescribed, and the 
tincture of the chloride of iron is the tonic generally preferred. Whatever 
the intensity of the febrile reaction and the stage of the disease, if there be 
no intestinal complication ferruginous or other tonics should be administered. 



CRETINISM. 469 

The largest doses of the tincture of the chloride of iron given in any of the 
cases in the above table were in Case No. 4 — namely, ten drops every two 
hours — and this patient recovered in seven days from a pretty severe attack. 
Probably, however, nothing is gained by such large doses, and they may 
irritate the intestinal surface and increase the liability to enteritis, which, we 
have seen, complicates a certain proportion of cases. Four drops may be given 
every three hours to a child from one to two years of age. Instead of the iron, 
or in addition to it, one of the preparations of cinchona may be prescribed. 

Erysipelas being an asthenic disease, it is very important that the diet 
should be highly nutritious and easily digested. Milk, perhaps peptonized, 
should be given freely, and the various meat peptones are also useful. 
Brandy or wine is also required. If vomiting be a pronounced symptom, it 
may be necessary to employ rectal alimentation. 



CHAPTER VII. 
CRETINISM (MYXCEDEMA). 

The term cretinism has long been employed to designate a remarkable 
disease which is endemic in certain localities in both hemispheres, and also 
occurs in a sporadic form in places widely separated. It was regarded as a 
disease mainly of infancy and childhood until 1873, when Sir William Gull 
published his observations on what he designated " a cretinoid state super- 
vening in adult life in women," and Ord gave it the name myxoedema, 
which is still retained to designate cases which commence in adult life. 

I shall apply the term cretinism to cases which begin in infancy or child- 
hood or come under observation as cretins during these periods. It is 
known that a large proportion of cretins manifest symptoms of the disease 
in infancy, or at so early an age that their cretinism is properly regarded as 
congenital. Thus in his instructive paper on this malady, read before the 
New York Academy of Medicine, Dr. Crary relates the case of a female in 
whom the symptoms had continued during the entire life ; and at the age of 
five years, when the child was not larger than an infant of ten months, 
and different physicians had examined her, the correct diagnosis was first 
made. The cretinism in this case, as in many others having a late diagnosis, 
was evidently congenital. We shall see hereafter that many of these dwarfs 
suffering from cretinism have been treated for months by prominent physi- 
cians for chronic Bright's disease. 

Cretinism occurs in many places widely separated in the Alpine chain, 
which traverses Switzerland, Piedmont, and Lombardy ; upon the northern 
slopes of the Apennines and southern slopes of the Pyrenees ; in Savoy ; 
along the banks of the Danube and Traun in Wurtemberg ; in the Black 
Forest ; in the valley of Ojat, Russia ; Irkutsk, Siberia ; on both slopes of the 
Himalaya ; and in parts of Cochin China and Burmah. In the Western 
hemisphere cretinism occurs along the valley of the Magdalena River ; in 
certain parts of New England, New York, Ohio. California ; but in no part 
of the Western hemisphere have cases been numerous, so far as I can learn. 

Although cretinism occurs over greater and smaller areas in so many 
localities, sufficient investigations have not been made to determine the influ- 
ence of climate, soil, altitude, or the habits and conditions of the people 
bearing upon its causation. 

I have not been able to ascertain that any abnormal state of either parent 
or in their mode of life acts as a predisposing or exciting cause of cretinism 
in their children. In this country only one in a family or circle of relatives 



470 CONSTITUTIONAL DISEASES. 

is, as a rule, affected. But the fact that it is endemic in certain localities for 
a long series of years encourages the belief that the local cause or causes, 
which seem to act by destroying the thyroid gland or antagonizing its func- 
tion, will yet be discovered. 

No other disease presents to our consideration more anatomical characters 
than this. Prudden and Delafield say : " The most marked and constant 
lesion in this disease is an atrophic condition of the thyroid gland. The 
parenchyma is more or less completely replaced by the fibrillar connective 
tissue and by new-formed reticular tissue, resembling the lymphatic tissue of 
the lymph-nodes. The fat-tissues may be atrophic, and the subcutaneous 
tissue has been shown in some, but not in all the cases, to contain an unusual 
amount of mucin. In certain patients the fibres of the upper or external 
part of the corium are crowded apart by fluid." 

Among the anatomical characters pertaining to the circulatory system 
may be mentioned diminution of the relative number of red corpuscles, also 
of the haemoglobin ; white corpuscles normal ; hypertrophy of left ventricle ; 
intestinal myocarditis, endarteritis ; atheromatous and amyloid degenerations. 
The patient is liable to headaches, anaphrodisia, rheumatoid pains, low tem- 
perature (95° to 98°), pulse weak and slow, respiration 17, urine of low spe- 
cific gravity, 1008-1014, diminution of urea ; sometimes the presence of 
albumen in small amount, with a few hyaline and granular casts ; has 
variable appetite ; constipation ; frequent and painful micturition. 

The body of the cretin is always short and thick. When fully devel- 
oped its height is from 3 i to 4 J feet; its cutaneous and subcutaneous circu- 
lation is slow, and the action of the heart is generally not strong ; sutures 
and fontanelles of the cranium slow in closing ; the teeth grow slowly and 
blacken and decay early. The patient has atrophy of the hair-follicles ; 
many have a dry and scaly scalp, which supports a coarse growth of hair 
coming down low on the forehead, but the hair is absent or scanty upon the 
axillae and pubes ; expression of face dull ; it is large and broad, with the 
usual lines, depressions, and prominences wanting ; eyelids cool, smooth, and 
dry, appearing thickened, so as sometimes to nearly obstruct vision by their 
swelling and approximation to each other ; nose swollen, short, and flattened ; 
lips large, thick, and pendulous, and of a dark violet color ; tongue large, 
thick, protruding, and only partially covered by the lips ; it is moved with 
difficulty, so that the partaking of solid food, or even liquid food in severe 
cases, is not easy, and it is in some patients regurgitated. The fact that there 
is the appearance of general oedema, and yet the pitting or pressure is very 
slight, has been alluded to by various writers. The explanation of this given 
by Delafield and Prudden has been, I believe, generally accepted : " The fat- 
tissues may be atrophic, and the subcutaneous tissue has been shown in some, 
though not all of the cases, to contain an unusual amount of mucin. In 
some cases the fibres of the upper layers of the corium are crowded apart by 
fluid." The small size of the interspaces in the superficial part of the corium 
and the viscidity of mucin afford explanation of the fact to which we allude. 

Hectic spots occasionally occur over the malar bones, and sometimes parts 
of the surface, especially the hands and face, have a yellowish or mahogany 
color or that like Addison's disease. As is seen in all the illustrations, the 
skin of the abdomen is pendulous and flabby and the swelling of the breasts 
nearly or quite conceals the nipples. Breathing through the nostrils is slow, 
and if for any reason it is accelerated, dyspnoea results. The swelling of the 
Schneiderian surface embarrasses respiration through the nostrils, and snoring 
during sleep is common. A muco-sanguinolent or reddish-brown stain, occur- 
ring during sleep, is sometimes observed upon the pillow, having oozed from 
the nostrils or mouth. 



CRETINISM. 471 

Warm weather is useful to these cases, and during the heat of summer 
certain cases may improve. The general paresis is such that some patients 
are scarcely able to stand without support, even at the age of four or five 
years. Bramwell says that the walking, or waddling as he expresses it, is 
like that of the hippopotamus. 

Cretinism affects equally body and mind ; it arrests bodily and mental 
growth and development. While at the age of four or five years the cretin can 
scarcely stand or walk without support, at the same time his speech lacks 
intelligence and sound and consecutive thought, and is likely to be indistinct 
or monosyllabic. 

Cretinism, when it pursues its normal course uninfluenced by medicine, is 
chronic. It may continue many years, with occasional amelioration of some 
of the symptoms, but only for a brief time. Death occurs in a comatose 
state. If the patient reach adult life, he is still physically and mentally de- 
generate till the close of life. 

Diagnosis. — Cretinism has such pronounced anatomical and physiological 
characters that the diagnosis is easy when the physician has once observed a 
case. Yet in many instances a mistaken diagnosis has been made because the 
physician is not familiar with it and the disease is in its earty stages. It has 
been and is most frequently mistaken for chronic Bright's disease. The gen- 
eral oedema in the one from mucin, and in the other from serum; the albumen 
and occasional casts in the urine and the general weakness which occur in 
both diseases have led to cretinism being mistaken for Bright's disease, and 
vice versa. The oedema not pitting, not affected by gravitation or but slightly 
affected, no perspiration, with a rough and dry skin, coarse, " wiry " and scanty 
hair, and other diagnostic symptoms which are related in this paper suffice for 
the exclusion of Bright's disease. 

The following case of congenital cretinism was presented by J. P. West, 
M. D., of Bellaire, Ohio, to the Eastern Ohio Medical Society, July 10, 1894, 
and January 8, 1895 : 

July 10, 1894 : A congenital cretin, now seventeen and a half months old, was 
born and has lived about a mile from Bellaire, on a hill four hundred feet above the 
Ohio River. She is the third of four children ; the other three are boys. The oldest 
died, when six months old, of cholera infantum. The second child is four years old, 
and the youngest nine weeks. These are very healthy children. The father, a farmer, 
is twenty-seven and the mother twenty-two years old, both being healthy. There is 
no history of any hereditary disease nor of goitre, nor is there any goitre in the 
vicinity. 

The labor was normal, the child small, weighing about six pounds. For the first 
few months nothing appeared wrong with the baby, although the mother saw she was 
slower about noticing things than her other children had been, and would lie unnat- 
urally quiet for long periods, often paying no attention whatever to her voice or to any 
noise. As time passed she showed no desire to sit alone and seldom a desire to raise 
her head. Her mouth was always open, her tongue protruding ; she took no notice 
of her surroundings, and it was with the greatest difficulty that her attention could 
be attracted. She was now about nine months old, and it was evident to the pa- 
rents there was something wrong, but it was believed she would outgrow it. 

When seventeen months old she weighed fourteen and a half pounds and was 
twenty-three inches in height. Her skin is thick, harsh, dry, and yellowish. Over 
her shoulders and arms there is some roughness and peeling of the skin ; this often 
occurs on the feet also. The head is flat, with a low forehead and prominent parietal 
eminences. The anterior fontanel widely open ; at times flat, at others full. Her 
hair coarse, rough, and scanty ; eyes dull ; the lids red and puffy, and cover the 
lower half of the cornea ; nose is broad and flat ; mouth always open ; lips very thick : 
neck short and thick ; no thyroid gland felt ; chest rather narrow ; a small swelling 
can be felt where each rib joins its cartilage ; abdomen full, prominent, and hard : 
umbilicus protruding ; abdominal organs normal : the hands short and stubby : legs 
short, thick, and bowed ; joints of the extremities somewhat enlarged ; some lor- 



472 CONSTITUTIONAL DISEASES. 

dosis ; temperature varies from 97f° to 99° F. in the rectum ; breathing almost 
always noisy, as if there were naso-pharyngeal obstruction ; respiration 24 ; pulse 
96. I have never heard her cry but once, when it was most peculiar and distress- 
ing. When crying she first becomes very restless, then opens her mouth wide, 
shuts her eyes tight, gets very red in the face, and emits a sound resembling a 
grunting cough. This sound is repeated again and again, from twenty to forty 
seconds apart ; the face in the interval is held firmly in the position just described. 
Her laugh, which I have never heard, is said to be as peculiar as her cry. 

Is good-natured ■ can be made to laugh, and seldom cries ; often lies perfectly 
still ; breathes slowly and quietly, and cannot be aroused. Occasionally, when laugh- 
ing or crying, or even when still, she almost strangles ; becomes blue in the face, and 
it is only with difficulty she can be brought to her normal condition. This occurs 
without recognizable cause, may be repeated two or three times in a day, or may 
not occur for a week at a time ; seldom sweats, and never freely ; takes but little 
food, and that milk ; is very costive. 

On July 20, 1894, she was put on Crary's glycerin extract of the thyroid 
gland, one and a half drops three times a day. After taking this two weeks she 
became feverish and fretful, and the dose was diminished, and stopped entirely from 
August 4th to 7th, then was begun again and kept up until August 23d. From this 
time until the present she has taken almost uninterruptedly one grain of the pow- 
dered thyroid twice a day. In the latter part of August she was sweating so pro- 
fusely about the head, particularly when asleep, that only one grain daily was given 
during the first ten days of September, but as this had no effect on the sweating, 
she was put back on the two grains. On October 15th and again on December 10th 
three one-grain doses were tried, but she could not tolerate this amount, and we 
continued with the two grains. For three weeks in July she took fluid extract 
of cascara sagrada for the constipation, after which she had no trouble with her 
bowels. On September 20th she was ordered five- to ten-drop doses of cod-liver oil 
and a small teaspoonful of cream three times a day. This treatment was continued 
until the latter part of November, when it was thought best to discontinue it, as the 
sweating had ceased and she was becoming quite fat. 

The child had not been under treatment quite four weeks before some improve- 
ment could be noticed. Her skin was not quite so thick and yellowish, her lips and 
tongue not so large, and her attention more easily attracted. During August there 
was a gradual and very perceptible change, and a new growth of hair appeared. 
On September 20th I noted that there was a considerable growth of new hair, 
which covered most of the scalp, was finer, and not harsh and wiry like the old ; 
on the sides of the head dark-brown, much darker than on the other parts of the 
head. She plays most of the time and notices everything said to her and given 
her. She will lie on the floor for an hour playing with her feet and trying to put 
them in her mouth. She turns her head quickly when spoken to, and looks at one 
intelligently. 

October 1st : Is twenty-five inches in height. Weighs sixteen and a half pounds. 
Her abdomen has lost two and a half inches and her chest gained one and a half. 
The anterior fontanel is one-third smaller ; skin not so yellowish nor so thick. 
There is a little peeling over the knees and front of legs. She holds the head up 
with but little effort, has a pleasant expression, smiles, and is easily made to laugh. 
The cry and laugh have lost their former peculiarities and are now perfectly natural. 
The eyelids are swollen but little, her lips are not so large, and the tongue is very 
seldom out of the mouth. A few hard papules are scattered over her face. Her 
hands are not quite so " spade-like,' 1 but she retains her stumpy look. 

November 1st : The improvement noted above has continued, and she has gained 
in every way. All the old hair is gone. The head is not so flat nor square, the 
fontanel only one-third its former size. The tongue no longer protrudes, and the 
mouth is assuming a much better shape. The skin is smooth, soft, and clear. She 
eats and sleeps well, and plays most of the time, knows all the family, and exhibits 
considerable jealousy toward her younger brother. 

January 8, 1895 : Her improvement has been steady and rapid. There is no 
evidence now that would indicate that this child was a cretin, except her height. 
She is several inches shorter than she should be and still looks somewhat stumpy. 
Notice that her skin is as soft and clear as any child's. Her hair is plentiful, soft, 
and silky, while before it was scanty and wiry. The expression of her face is 
bright, and she knows all that goes on about her. She will try to cough and 



CBETIXISM. 



473 



sneeze, and do many other things when told. Her eyelids are no longer swollen 
and baggy. Her tongue is perfectly normal, and her mouth anything but repul- 
sive. During her waking hours she is continually on the move. I call your atten- 
tion, particularly, to her abdomen and umbilicus, and the changes that have taken 
place here. The abdomen is not larger than it should be and the umbilical hernia, 



J lilt; 11 IS llUL ictigci Liictii it biiuuiu uc ciiju. tiic u.111 Fjn±^a>± nciiua 

present at first, is gone. On October 1st she cut her two lower incisor teeth, the 
November 27th and the second ..December 7th, the two upper 



first upper incisor on 



Fig. 63. 



Fig. 64. 





Case of cretinism described above. 



The same ease after six months' treatment 
with the thyroid extract. 



lateral incisors in the middle of December, and the two lower the latter part of the 
month. She began sitting alone the middle of November, and now can stand by 
holding to a chair. She cannot crawl, but you would be surprised to see how fast 
she can go across a room by rolling over and over. 
This table will afford an idea of her improvement : 



Weight 

Height 

Neck 

Chest . 

Abdomen 

Circumference of head 

Ear to ear 

Nose to occiput . . . 




474 CONSTITUTIONAL DISEASES. 

Treatment. — The remarkable fact has been established by many obser- 
vations that the thyroid gland contains some substance which, administered 
to cretins, exerts a curative effect. Without this ductless gland, which until 
recently was supposed to be superfluous, it now appears that man would be 
reduced to a state of feebleness and imbecility. There is no branch of the 
human race which does not have more mental activity, and which is not more 
competent to reduce and utilize the forces of nature, than the cretin, so that 
if we all lacked this substance which the thyroid gland contributes to the 
system, and which elevates and energizes the action of the brain. — if, in other 
words, all human beings were cretins, the condition of the race would be 
deplorable. 

By the use of the thyroid gland as a medicine taken by the mouth or by 
subcutaneous injection the prominent symptoms of cretinism gradually dis- 
appear, and the patient approaches more and more the normal state of devel- 
opment and growth. The temperature, pulse, and respiration become more 
normal. In most cases gradual improvement occurs under correct treatment 
in the many particulars in which the disease manifests itself. 

Since the thyroid gland has been recognized as the efficient curative 
agent of cretinism, it has been employed in various ways. Murray's original 
preparation is most used. It contains one drachm of the expressed juice, 
one drachm of glycerin, and one-half of 1 per cent, of the aqueous solu- 
tion of carbolic acid. Five to fifteen minims are injected two or three times 
daily under the skin. A flushed face, pain when the remedy is inserted, 
which is by preference in the lumbar region, indicate that the remedy should 
be discontinued. In all cases of the use of the glycerin extract the glands 
are carefully cleaned, minced, and 24 grains are added to 1 drachm of gly- 
cerin, and after maceration with the glycerin the mixture is allowed to 
stand, after which it is filtered by compression. Full antiseptic precautions 
are used in the process of preparing the gland, and the glycerin is sterilized 
previously, and diseased glands are rejected. The medicine when prepared 
should be kept from heat and light. At the beginning of treatment the 
dose of this preparation should be for an adult 5 drops three times daily, 
with a gradual increase to 15 drops. In the treatment of infants 1 drop of 
the above, three times daily, is sufficient at first, and the maximum amount 
attained by gradual increase should be perhaps 4 drops four times daily. 

In the opinion of Dr. Crary this medicine prepared from the thyroid 
glands of lambs is more effectual than that from older sheep. 

Case. — Eelated by Dr. G. W. Crary, D. D. : Female, aged five years, born in 
Boston of New England parentage ; an only child. The mother has had an irri- 
table and rapid heart, and is anaemic. During the period of her gestation, ending 
with the birth of the child, she was constantly nauseated. She had also tonsillitis 
for five weeks, and a broken rib by an accident in the third month of gestation. 
The birth was instrumental and the cord was around the neck. The child at birth 
was apparently normal, weighing eight pounds. The first symptoms of cretinism 
were noticed at the age of three months. The tongue was apparently thick and 
she was pronounced tongue-tied. She weighs at five years fifteen pounds ; has 
chronic constipation. At the age of four months she cried much, and had attacks 
of dyspnoea ; at six months ceased to grow and lost weight : at eight months the 
abnormal development in different ways was first noticed : the swollen and pro- 
truding tongue, swelling of the cheek, lack of bodily and mental development, 
were apparent, but the disease was not diagnosticated until after the age of five 
years. At this time the child was of the size of a ten months' infant. 

The following symptoms indicated clearly the nature of the disease : Slight 
mental perception ; a lighted match did not attract attention ; loud noises caused 
her to turn, but she could not locate them ; no response to the call of her name ; 
disposition good ; when placed upon her back turned with difficulty upon her face 



CRETINISM. 475 

and abdomen ; -when sitting upon the floor usually fell prostrate without effort to 
prevent falling : hair of scalp thin and coarse, but present upon forehead and sides 
of face ; temperature 97°-9S° ; anaemic. 

"We will now relate the mode of treatment : " I have used the glycerin 
extract in all cases, and make it of a strength of 24 grams of the thyroid 
gland of the lamb to 1 drachm of glycerin. The glands are carefully 
cleaned, minced, and after maceration with the glycerin the mixture is 
allowed to stand for three or four days, after which it is filtered under pres- 
sure as required for use." 

One drop, three times daily, of the above medicine was at first adminis- 
tered. This was gradually increased until 4 drops were given, and the tem- 
perature arose to 99°. On September 19th the appearance was better, with 
more notice of objects. On September 27th, 5 drops were taken and the 
temperature was normal ; swelling of body, face, and lips much reduced ; 
tongue swells and more movable, and could be kept within the lips, but not 
within the closed jaws ; skin soft and more moist ; bowels normal ; is brighter, 
and turns her head in the direction of the voice. On October 5th and 6th 
the quantity administered of the extract was 15 to 16 drops daily, and her 
temperature was 101°. The dose was therefore reduced to 3 drops three 
times daily, but she was far advanced toward recovery. 

October 16th, improvement of body and mind continues. The circumfer- 
ences of the head, face, upper extremities, and upper part of the trunk have 
diminished. 

Dr. Crary states that the effects of the thyroid administration may be 
summed up as follows : Increased metabolism, shown by — 

1. Elevation of temperature ; 

2. Increased appetite, with more complete absorption of nitrogenous food; 

3. Loss of weight, with nitrogen excreted in excess of that taken in the 
food ; 

4. Growth of skeleton in the very young ; 

5. Marked improvement in body-nutrition generally ; 

6. Increased activity of mucous membrane, skin, and kidneys. 

If the patient has recovered or is well on the way to recovery, still the 
medicine should not be omitted entirely, but may be given in less frequent 
doses. 



SECTION IV. 

MALFORMATIONS AND DEFORMITIES. 



CHAPTER I. 

THE DIGESTIVE ORGANS. 

Lips and Palate. 

Atresia Oris, Microstoma, small mouth, congenital or acquired, requires 
treatment either by dilatation or operation. Dilatation is a slow and tedious 
process, and must be persevered in for a long period to effect satisfactory 
results. The tendency to contraction is very great. In general it is better 
to enlarge the mouth laterally, and draw the mucous membrane over the 



Fig. 65. 



Fig. 66. 





Cicatricial contraction of mouth. 



Large mouth ; pendulous growths near ear. 



wound and attach it to the margin of the skin. If union is secured, the result 
will be satisfactory. If it fail at any point, the operation may be repeated. 

Macrostoma, or congenital enlargement of the mouth, is due to a failure 
of union of the superior maxillary and the frontal, nasal, and external nasal 
processes. It is usually unilateral and can readily be remedied by carefully 
paring the edges and uniting them by suture. 

Fig. 67. Fig. 68. 



Fig. 69. 




V ; 




Showing the development of the 
intermaxillary. 



Harelip, congenital 
cicatrix. 



Harelip as slight 
notch. 



Harelip is a congenital non-union of the central, or of the central with 
476 



THE DIGESTIVE ORGANS. 



477 



the lateral portion of the upper lip, cleft corresponding with the junction 
of the intermaxillary or of the maxillary and intermaxillary bones (Fig. 67) ; 
it is most common in males and is frequently hereditary ; it may be single, 
double, or complicated. 

The fissure may be a slight cicatrix, the first indication of harelip (Fig. 68), or 
a short notch (Fig. 69) : but in general it extends to within a little of the nostril, 
and is often continuous with it 
(Fig. 70) : when double it may be of 



Fig. 70. 



Fig. 71. 





Uncomplicated double 
harelip. 



Fig. 72. 



the same size on each side (Fig. 71), 
or there may be a short notch on one 
side and an extensive one on the 
other ; the substance of the lip al- 
ways varies much in such cases, be- 
ing thick and fleshy in some and in 
others thin and defective in all re- ■*&"■■ 

spects. and the breadth of the gap Harelip as deep fissure on 
usually varies in accordance with right side, 

these characters. There is always, 

even in the worst cases of double cleft, an intermediate portion of lip which may 
be broad or narrow, long or short, thin or of the natural thickness of the lip, 
but generally it is deficient. 

The general rules of treatment are : (1) If the infant is feeble, delay 
operation until after the third month ; (2) if healthy and the cleft single, 
operate, if it is desired, immediately ; (3) if there is no 
special urgency, delay till from the third to the sixth 
month (the comparative mortality in the different periods 
favors the latter course) ; (4) when there is inability to 
take food operate at the earliest moment ; (5) defer the 
operation if diarrhoea or eruptive diseases are present ; 
(6) the midsummer months are very unfavorable ; (7) 
if the harelip is double, wait until the child is two or 
three years old, unless the conditions render an earlier 
operation necessary ; (8) chloroform is not necessary in 
infants : (9) cleanse the mouth, gums, lips, and nose with 
boric-acid solution. The stages of the operation are : (1) 
The infant, having a sheet wrapped around its body so as 
to enclose its arms, should be held upright in the arms of 
an experienced assistant, and its head firmly grasped by a 
second assistant (Fig. 72) ; the older child should recline 
with its head raised ; (2) separate thoroughly all adhe- 
sions to the gums, so that the two flaps move freely ; (3) 
make section of the edges of the cleft with strong scissors 
or with the knife, and in such form as will most completely obliterate deform- 
ity when the flaps are placed in perfect apposition ; (4) close the wound with 
harelip pins if the tension is great, and with silver-wire suture if it is but 
slight ; introduce the suture or pins so deeply as to reach, but not to pene- 
trate, the mucous membrane. Thomas of Birmingham restores the cleft into 
the nostril several days before completing the operation. The flaps rarely 
require any other support until the sutures or pins are removed. 

Partial fissure of the lip is best treated by two incisions which meet at a 
point above the tip of the fissure, and extend into each flap without dividing 
the margins (Figs. 73, 74) ; the double flap thus formed is depressed, the 
apex presenting downward, and the wound then becomes diamond-shaped. 
On closing the wound there is a pouting of the lip which gradually disap- 
pears, leaving no deformity. 

Single harelip may occur on either side, and may vary in extent from a 




>per£ 

lip: position for 
young patient. 



478 



MALFORMATIONS AND DEFORMITIES. 



slight indentation to a complete division into the nostril. The two sides of 
the cleft differ in their regularity, being on different levels and variously 
bevelled at the angles. If the knife is used, enter it at the angle and cut 



Fig. 73. 



Fig. 74. 



Fig. 75. 






Nelaton's operation for partial harelip. 



Operation for single harelip. 



away a sufficient portion to make the margin straight and secure easy and 
perfect adjustment ; at the free border (Fig. 75) turn the edge inward to the 
cleft, to avoid the notch in the lip and save a portion of the mucous mem- 
brane. If the scissors are preferred, the same section can be made. If the 
free borders are irregular and round, the method of saving the parings should 
be adopted — namely, make an incision from A B (Fig. 76) through the thick- 
ness of the lip down to the mucous membrane, but not through it, and turn 
the flap back ; on the other side transfix the lip at C and separate a flap as far 
as Z>, dividing it at E ; bring the two sides together and attach the flap, E, C, 



Fig. 



Fig. 77. 



Fig. 78. 






Collis's operation for harelip. 



Malgaigne's operation for harelip. 



to J. by a suture, and the flap, E, D : to B ; apply two intermediate sutures, 
and the result will be a lip nearly double the depth (Fig. 77) of that obtained 
by the ordinary method ; the same result follows if the two portions, pared 
off the sides of the cleft, remain attached to each other (Fig. 78), as well as 
to the free edge of the lip, and are turned downward and the two sides are 
united as before. This method is peculiarly appropriate to clefts which do 



Fig. 79. 



Fig. 80. 





Harelip : Giraldes's method. 

not extend through the whole depth of the lip, but terminate at some dis- 
tance from the nostril. 

In cases of very extensive cleft, or with a projection of one portion of 



THE DIGESTIVE ORGANS. 479 

the jaw. the following operation is advised : Cut flaps on either side (Fig. 
79) and leave them attached, one, C, by the lower, and the other, J., by the 
upper end. the incision being carried around the nose as far as may be deemed 
necessary, E ; the flap attached by its lower end, C, is then turned downward 
so that its red edge forms the border of the lip, while the other, JL, is drawn 
upward toward the nostril, and they are thus dovetailed together (Fig. 80) 
with interrupted suture. 

In some cases the continuity of the lip border may best be preserved by 
the following method : Remove the edge of one of the borders clearly 
throughout ; on the other cut a flap with its pedicle below ; bring the edges 
together so that the flap is applied from below upward upon the notch. If 
the flaps in any case do not promptly unite and the edges continue to granu- 
late, they should be maintained in apposition for the purpose of securing union 
by granulation. 

Double harelip may exist with or without defect in the bone. When 
complicated with fissure of the hard palate, the best-conducted operations are 
very liable to fail. If the clefts are limited to the lips (Fig. 81), and there 
is not severe tension, operate upon both sides at the same time (Fig. 82) ; but 

Fig. 81. Fig. 82. 




Double harelip. 

if the traction upon the parts is great, operate upon one side at a time, mak- 
ing a central flap, which can be attached at the sides and to the angles of the 
flaps (Fig. 82) ; first make the incisions, B and A ; then pare the edges of the 
projecting mass C; turn the flaps, A and B, downward and unite them. The 
result is good (Fig. 82). 

If the intermaxillary bone has not formed ossific union, it projects more 
or less, according to its attachments to the septum nasi. Except when it is 
a mere pendulous mass from the tip of the nose, efforts should be made to 
save it, both because it contains the sacs of the incisor teeth, and its presence 
is necessary to maintain the form of the upper jaw and lip. In the slighter 
cases of projection of the intermaxillary bone it is merely necessary to frac- 
ture its attachment to the septum and press the mass back into position, or, 
if it be too large to fill the gap, the exuberant parts must be pared away at 
the sides, the adjacent sides of the superior maxillary bones refreshed, and any 
teeth projecting across the cleft removed. 

A wedge-shaped piece maybe cut from the septum, which allows the mass 
to recede more readily into the cleft (Fig. 83) ; a suture may be applied to 
the sides of this notch to retain the depressed bone in place. The bone has 
been retained in position by silver sutures passed through it and the adjoin- 
ing hard palate, but three teeth were destroyed by the penetration of their 
sacs. The bone has been successfully held in position by at once uniting the 
clefts in the soft tissues. When the flaps are insufficient to close the cleft, 
they may be dissected away from the cheek to such an extent as to admit of 
their easy approximation. If the process is tedious, it should be divided into 



480 



MALFORMATIONS AND DEFORMITIES. 



stages, dealing first with the projecting intermaxillary bone, and then with the 
soft parts. When the mass is merely suspended from the tip of the nose, 



Fig. 83. 



Fig. 84. 



Fig. 85. 





Before operation. 



Front view. 



Side view : after operation. 



it must be removed by careful dissection with strong scissors, the soft parts 
being retained and so placed as to form a columna nasi or to fill the gap in 
the lip (Fig. 84). The result is very favorable (Fig. 85). 

The use of an oesophageal tube to feed the child after operation may be employed to 
prevent the contact of food with the wound. 



Hypertrophy of the mucous glands is characterized by 
dulous portions of tissue appearing on either side of the 
86), and is due to an increase of the glands of the part and 
membrane. Make a straight or elliptical incision in the line 
the submucous tissue ; close the incision with fine sutures. 

Hypertrophy of the lip generally occurs in scrofulous 
sists in chronic thickening of the deep structures. It may 



two elevated pen- 
middle line (Fig. 

not of the mucous 
of the lip ; 



excise 



subjects and con- 
result from a con- 



Fig. 86. 



Fig. 87. 





Hypertrophy of mucous glands of lips (Bryant ). 



Hypertrophy of lip (Buck). 



genital enlargement of capillaries constituting a nsevus (Fig. 87), and then has 
a raspberry discoloration, is flabby, pendulous, and contains hard knots in its 
substance. Operate as follows : Remove a V-shaped patch, equidistant from 
the angles of the mouth, and having its apex low down in the median line 
under the chin ; divide the mucous membrane along the line of its reflection 
from the jaw on either side of the wound; bring the opposite edges of the 
wound together and secure them in exact coaptation by pin-sutures inserted 
at equal distances from each other below the lip-border ; between every two 
pin-sutures add a silver wire, and on the vermilion border fine thread sutures, 
one being on its buccal surface ; when union is complete, a second operation 
is required to reduce the thickness of the lip. This is effected by two parallel 
incisions, including one-third of the thickness of the lip and penetrating deeply 
into its substance. The raspberry color must be destroyed by the galvano- 
cautery. 



THE DIGESTIVE ORGANS. 481 

The Tongue. 

Tongue-tie is a congenital malformation in which the fraenum linguae 
extends too far forward toward the point of the tongue, and remains rather 
below its natural height, measured from the floor of the mouth ; protrusion 
is hindered, and where the defect is great the tongue cannot be applied 
against the roof of the mouth ; the slight form is harmless, but the severe 
form presents a great obstacle to sucking ; in the latter case it is advisable 
to operate. Division has been followed by fatal hemorrhage from the ranine 
arteries, but carefully performed it is without danger and painless ; pass the 
first and second fingers of the left hand, palm downward, under the tip of 
the tongue on either side of the fraenum, and put it well on the stretch ; 
snip the edge of the fraenum with blunt-pointed scissors below the fingers, 
thus escaping the ranine arteries, which run along the lower surface of the 
tongue ; push the tongue upward against the roof of the mouth, and divide 
further, if necessary ; this method is preferable to the use of the cleft in the 
handle of the ordinary director. 

Hypertrophy of the tongue is usually congenital, and may be noticed 
immediately after birth, or may appear later, being uncertain in its rate of 
growth ; when fully developed the tongue protrudes, 
with constant dribbling of saliva, and causes deformity ■ Fig. 88. 

(Fig. 88) of the jaw. The treatment by pressure and 
astringents may first be attempted, as follows : Apply 
daily cupri sulph. 9j to aq. Jj on lint, and compress 
with a bandage. If these means fail, removal is the 
only alternative. Excision is very dangerous when the 
organ is large, owing to hemorrhage ; the knife, ligature, 
ecraseur, or galvano-cautery may be employed ; when 
the knife is used the flaps may be made by transfixing 
the tongue laterally or vertically ; the former method 
is, in general, preferable, as the thickness of the tongue 
is thereby much more reduced. 

The head being supported against the breast of an assist- Hypertrophy of the 
ant, who retracts the angles of the mouth, seize the tongue tongue (Buck), 

with forceps on its edges, and draw it well forward ; pass a 

strong ligature transversely through the back part of the tongue with which to 
draw the organ forward ; transfix the tongue from side to side at the point where 
excision is to be completed, and cut forward and downward through its under sur- 
face, making the lower flap ; form the upper flap by cutting in a reverse direction, 
backward and downward, to the point where the first section had commenced ; 
ligate the arteries and secure the flaps in contact with sutures ; recovery with a 
flattened tongue and good speech results. 

A vertical incision may be required, in order to remove a V-shaped portion of 
sufficient size, and bring together the lateral flaps so as to form a new tip, which 
shall fall within the teeth ; the patient, anaesthetized, being placed with the head 
elevated and held by an assistant, pass the knife through the substance of the 
tongue external to the middle line, to avoid the ranine artery ; cut out a flap, and 
tie all the bleeding vessels ; pass a strong ligature through this flap to prevent the 
tongue falling back ; enter the knife at the same point ; carry it across the middle 
lines, dividing the ranine arteries, which must be tied before the flap is finally 
separated ; close the wound with strong sutures thus : Introduce theue sutures into 
the lateral flaps, and on tying them the tip of the tongue assumes a natural appear- 
ance. Removal by the ecraseur involves less immediate risk from hemorrhage, but 
is liable to be followed by dangerous inflammatory swelling. If employed, proceed 
thus : Pass the chain of a very stout instrument through the substance of the 
tongue at the same point as in excision by the knife, and when it has worked its 
way outward a little, pass a second chain and work it at the same time toward the 
opposite side. 
31 




482 



MALFORMATIONS AND DEFORMITIES. 



Angeioma, vascular tumor, may be venous or arterial ; the former is 
common, the latter rare. Venous angeiomas are generally congenital, may 
be single or multiple ; usually appear on the anterior part of the dorsum, 
projecting slightly above the surface, thinning the mucous membrane over 
them, and showing a dull blue or livid color ; in some the contents may be 
pressed out, and in others the mass feels tense and elastic like a thin cyst 
filled with fluid ; they are usually quite painless, seldom very large, and not 
inconvenient except from their bulk and occasional liability to bleed. They 
may diminish and disappear, or increase, or undergo warty degeneration. 
They are composed of numerous anastomosing vessels, or are cavernous. 
The treatment is destruction by the actual or galvano-cautery, the latter 
being preferable. The point of one of the platinum instruments, at a dull- 
red heat, should be made to penetrate deeply into the substance of the 
growth, and moved in all directions through it until it has been completely 
broken up ; repeat the operation if necessary. 

Papillomata, warty tumors, occur, usually, on the dorsum within the 
papillary area, and are then due to hypertrophy of the natural papillae ; they 
may grow on the under surface. They may be mistaken for condylomata or 
warty carcinomata ; the history of the case is the guide to a correct diag- 
nosis in the first class, and the age of the patient and the induration of the 
base determine the latter. In children the hypertrophied papillae may be 
destroyed by the solid nitrate of silver ; the larger pedunculated growth may 
be removed with scissors or the ligature ; the larger papillomata should be 
removed with the knife or scissors. 



The Palate. 

Congenital Defects of the Palate. — Fissure or cleft of the palate, as a 
congenital defect, may involve : (1) only the ovula, 1 (Fig. 90) ; (2) the soft 

Fig, 89. 




Mouth-gag. 

palate, 2 (Fig. 90); (3) the hard palate as far forward as the middle of the 
palate process of the superior maxillae or through the palate bones only (Fig. 
91) ; (4) the alveolar ridge entire with the cleft of the palate (Fig. 92) ; (5) 
cleft or notch of the alveolar ridge with entire cleft of palate ; (6) double 
cleft of the alveolar ridge, with fissure from each running backward and in- 
ward and joining behind the intermaxillary bones, becoming continuous with 
a median fissure. 

There are also many grades of separation of the fissure. Usually the cleft in 
the palate is narrower in front and widens toward the velum, but in some the gap 



THE DIGESTIVE ORGANS. 



483 



will be very wide and in others very narrow, though complete from alveolus to 
uvula. In partial clefts the breadth is often much greater than is apparent from 
its extent, in some instances giving the greatest breadth met with. 



Fig. 90. 



Fig. 91. 



Fig. 92. 






Large fissure. 



Fissure of soft and hard palate. 



Slight fissure. 

The operations undertaken for the relief of fissured palate are staphylor- 
rhaphy and uranoplasty, the former being an operation on the soft, and the 
latter on the hard palate. 

If the uvula alone is bifid and the voice unaffected, it is better not to in- 
terfere with the fissure. As the articulation, however, is generally affected, 
closure by suture is the rule of treatment ; the operation may be performed 
at any age, but when circumstances are unfavorable to an early operation, it 
is better to defer it until the child is at least three or four years old, or even 
until adult life. If the patient is a child, chloroform should be given and 
the gag inserted (Fig. 93). 

Staphylorrhaphy, suture of the soft palate, is an operation which the 
surgeon need have no hesitation of undertaking when the cleft is limited. 

The child being properly supported by an assistant, clean the mouth with boric 
acid. First seize one point of the cleft with long spring forceps, draw it for- 
ward, transfix it near its inner border with a narrow, sharp knife on a long handle, 
and freely cut upward or down- 
ward and remove the mucous Fig. 93. 
membrane along the whole of its 
inner margin (Fig. 94) ; make the 
same section on the opposite side 
and divide the angle of union last. 

When the cleft extends for- 
ward through the whole of the 
velum, or even to a slight extent 
into palate bones, the operation is 
more complicated, for every at- 
tempt to bring the edges of the 
fissure together is opposed by the 
combined actions of the levator 
and tensor palati muscles on 
either side, drawing directly away 
from the median line at which the 
edges of the fissure should meet ; 
the muscles must therefore be 
divided to ensure success. The 
relaxation of the tissues of the 
fissured velum may generally 
be sufficiently secured by means 
of incisions made with strong 
curved scissors, so as to divide the 
posterior pillar of the palate just where it begins to spread out into the velum ; in 
some cases an additional stroke or two of the scissors is necessary to divide a band 




Whitehead's gag and tongue-depressor. 



484 



MALFORMATIONS AXD DEFORMITIES. 



Fig. 94. 




of firm tissue extending above and behind the soft palate. The division of the 

muscles is also effected as follows : Pass a suture 
through one section of the soft palate at the root of 
the uvula, secure the ends by a knot, and have it 
held outside the mouth ; repeat a similar suture on 
the opposite side 5 draw one of the sutures firmly, 
holding one-half of the soft palate to its opposite 
side, so as to stretch this section of the palate toward 
the median line ; recognize the hamular process in 
the substance of the soft palate internal and a 
very little posterior to the last molar tooth ; intro- 
duce the point of a thin, narrow knife fixed in a 
long handle, the blade down, a little in front and 
to the inner side of this process, and carry it up- 
ward, backward, and somewhat inward, until the 
point is seen in the gap, having passed through 
the entire thickness of the soft palate, and cut par- 
tially, if not wholly, the tendon of the tensor 
palati : raise the handle of the knife, depressing 
its point, and as the blade is drawn forward make 
it cut downward, so as to pass through a consider- 
able section of a circle on the posterior surface of 
the palate, by which the division of the greater portion of the levator palati is 
effected ; complete its section as the knife is withdrawn (Fig. 96). 

If the muscle is properly divided, all movements of the palate cease, and it 
becomes pendulous and flaccid : if there be any further resistance, reintroduce the 
knife and divide the fibres more freely. The divisions of the muscles may be made 
a day or two before the operation for closing the fissure, and thus avoid the bleed- 
ing : or the muscles may be divided after paring the edges, and inserting the 
sutures, the palate being put on the stretch by means of the threads held in the 
hand ; lateral incisions through the soft parts completely dividing the soft palate 
from its lateral attachments wili allow the two halves to fall together. 

The edges of the fissures should now be thoroughly denuded of mucous mem- 
brane. The suture selected should be silkworm-gut or Chinese silk, made antiseptic. 
First decide how many sutures will be required, and observe the points at which 
they should be inserted to correspond on each side ; the sutures in each needle 
should be at least one yard in length, and each suture should be doubled for its 
whole length before being passed ; with the needle in the right hand and a pair of 
long spring forceps in the left, push the point of the needle through the soft palate 



Showing the paring of the edges 
of fissures after the introduction 
of the sutures. 



Fig. 95. 



Fig. 96. 



Fig. 






Passing the suture. 



Sedillot's operation for 
staphylorrhaphy. 



Incisions to relieve tension. 



on the patient's left side, as near to its anterior margin as practicable ; seize one 
thread of the suture and draw it forward ; pass the needle on the opposite side 
with a double thread, the loop of which should be drawn out ; the needles being 
removed, the single thread of the one side is passed through the loop of the other, 
the looped thread withdrawn from the palate carrying the single suture through 






THE DIGESTIVE ORGANS. 485 

the opposite side (Fig. 95) ; repeat until the requisite number, three or four, is 
inserted ; tie each separately, and not too tightly, to allow for swelling ; a slip- 
knot ( Fig. 95) to bring the edges together, and a second knot over that, are suffi- 
cient (Fig. 96) : the ends should not be cut off very close. A perforated shot may 
be passed over the suture, and compressed to prevent slipping. If wire is used, it 
must be applied with the wire adjuster, be nicely twisted, and cut closely. The 
after-treatment must be carefully attended to ; the diet should be liquid ; no con- 
versation should be allowed ; the sutures may be removed after about eight days. 

To relieve tension, the soft palate may be incised (Fig. 96), or by the side cuts, 
B (Fig. 97). subsequently gaping so as to appear as arches. 

Uranoplasty, closure of fissure of the hard palate, may be undertaken at 
any age. yet as the real object of the operation is to enable the patient to 
articulate plainly and intelligibly, and as a child does not commence to articu- 
late, as a rule, before twelve months old, nor to pronounce many words before 
two years of age, the reasons are strong against its performance prior to this 
latter period of life, for the child is now in a much more favorable condition 
to undergo the operation, and less liable to succumb to the effects of the loss 
of blood. The early treatment, therefore, is the proper nourishment of the 
infant until it reaches the requisite age, and the mother's milk is the only 
food that should be given for the first six or eight weeks ; if the child cannot 
nurse, owing to the extent of the cleft, it must be hand-fed with her milk. 
The operation, whatever may be the extent of the fissure, consists in dissect- 
ing up the membrane covering the hard palate, quite back to the alveolar 
processes, including the periosteum, so as to form muco-periosteal flaps. The 
result will be successful in any case where the patient is fairly healthy and 
the parts can be brought together without undue tension. The closure is 
effected not only by these soft tissues, but also by bone subsequently repro- 
duced in the periosteal layer. As the success of the operation depends upon 
immediate union of the edges of the flaps, examine the patient carefully to 
ascertain if he is in a condition of health to justify the expectation of union 
by first intention ; if there are any signs of disordered health or defective 
power, as pustules, herpes, excoriated lips or nostrils, the operation should be 
postponed. The operation may be completed at one or at several sittings ; 
unless there are circumstances of peculiar difficulty in the case, which will 
make the operation either unusually tedious or will necessitate such an exten- 
sive division of the soft parts as would endanger the flaps, the whole cleft 
should be closed at one operation. In an ordinary case of cleft of the hard 
and soft palate proceed as follows : 

Place the patient, etherized, in a good light ; introduce the gag previously fitted 
to the mouth (Fig. 93) ; or, if the cleft is through the alveolar process also, select 
a gag which has no central roof portion. Operate first on the soft palate ; pare the 
edges of the cleft from below upward, the point of the uvula being held with for- 
ceps, b (Fig. 88), to render it tense ; apply the sutures from below upward, passing 
them, if possible, completely through both sides to avoid the loops described, and 
fastening each after the next is passed ; relieve the undue tension by longitudinal 
incisions on either side parallel with the cleft and just internal to the hamular 
process, avoiding the post-palatine foramen, or cut the muscles, seizing with the 
forceps, b (Fig. 88), the palato-pharyngeus muscles and dividing them with the scis- 
sors, f (Fig. 88), low down, and also the levator palati of both sides. When the 
soft palate has been closed and the point in the velum has been reached where the 
sutures can no longer be fastened, from the amount of tension, proceed to operate 
on the hard palate if the condition of the patient do not forbid it. Separate the 
soft tissues from the bone, commencing at the edge of the cleft and dissecting out- 
ward to the alveolar process, or, which may be preferable, from the alveolar border 
toward the fissure, as follows : Make an inscision close to and parallel with the 
alveolar ridge, from a point opposite the last molar tooth forward to the canine, 
and separate the flaps from the bone by means of the periosteotome, lu i (Fig. 88), 
commencing at the incisors and proceeding inward to the edge of the gap, avoid- 



486 



MALFORMATIONS AND DEFORMITIES. 



ing bruising the flaps ; these flaps should now fall inward and downward and 
meet in the median line without the slightest traction ; if the edges do not readily 
meet, the flaps have not been sufficiently detached, and search m-ust be made for the 
point preventing descent, which should be freely liberated ; pare the edges with a 
sharp knife so that two entire and fresh raw surfaces are brought accurately in con- 
tact ; pass the sutures as in closure of the soft palate. 

No special treatment is required, except to avoid giving warm food until 
Fig. 98. Fig. 99. 





A, preliminary puncture with awl to give line for chisel; B, incision through bone completed 
by chisel ; C, holes bored through hard and soft palates for sutures : D, junction of hard and 
soft palates ; E, E, lateral openings subsequently filled up by granulation. 

the day after the operation, and to abstain from looking at the palate ; give 
first iced milk, and afterward, for a fortnight, such food as eggs, milk, rice 
milk, cream custard, stewed fruit, arrow-root, soup, beef-tea, pounded meat 
with wine, brandy, or malt liquors ; children and delicate young persons should 
be kept in bed for a week, when practicable ; the sutures should remain three 
weeks or a month in children, and be removed under an anaesthetic. 

The following method of operating has given excellent results : Holes are 
drilled with a curved brad-awl through the margin of the hard palate (Fig. 98) 
for the passage of the threads, while the palate itself is then cut through with a 
chisel in a line parallel to and about half an inch from the cleft, B ; such step being 
facilitated by previously drilling the bone, A; this loosening of the margins of the 
hard palate allows the borders of the cleft to be brought together along its whole 
length after the margins have been pared and the stitches twisted (Fig. 99). 

It frequently happens that under the most favorable circumstances a small aper- 
ture will remain ; these openings are not unlike those slight congenital defects 
which appear in the palate as orifices, or which result from syphilitic caries ; they 
may be closed by subsequent operations or with a metal plate or with a hard-rubber 
obturator. 

Contracted soft palate frequently results from successful closure of the 
cleft, and leads to imperfect speech. With a view to lengthen the curtain or 
relieve the tension upon it, several operations have 
been performed : (1) The inner borders of the palato- 
pharyngeus muscles have been pared and united, but 
the operation had the effect of compelling the patient 
to breathe entirely through the mouth, without im- 
proving speech. (2) The attachments of the palate 
to the sides of the fauces, together with the anterior 
and posterior pillars, may be divided as follows : Pass 
a spatula behind the soft palate, 1, 2 (Fig. 100), both 
to steady and draw it forward ; then transfix the 
soft palate by a sharp-pointed bistoury by the side 
of the spatula and at the inner edge of the harnu- 
lar process, 1, 4, and cut through the free margin of 




Contraction of soft palate. 
the palate to 



(Fig. 100), dividing the tensor palati, palato-glossus, and 



THE DIGESTIVE ORGANS. 487 

palato-pharyngeus muscles ; retraction follows, 3 ; sutures are now passed 
through the sides of the flap from before backward, thus hemming the 
mucous membrane, 5 ; this operation is extremely simple, comparatively pain- 
less, and has always resulted in some, and in many instances marked, im- 
provements of the Voice. (3) Dissection of the palato-pharyngeus muscles 
to form flaps in connection with a raised portion of the mucous membrane of 
the prevertebral region was attempted, but not completed. Careful anti- 
sepsis must be practised. 

The Rectum. 

Imperforate rectum is caused by a membranous partition which may be 
just within the anus or an inch or more above ; it varies in thickness, but is 
usually thin ; the symptoms are retention of the meconium and vomiting. 
Examination with the finger or probe or a small elastic catheter or bougie 
determines its nature ; if the membrane is thick, it may not be possible to 
decide whether the intestine is continuous above till an incision is made, but 
if it is thin it will bulge down upon the finger, especially when the child 
cries. Delay the operation a day or two, until the meconium dilates the lower 
part of the intestine ; if the septum is thin, break it down with the end of 
the little finger ; if thick, puncture with a sharp-pointed bistoury, the blade 
being wrapped with thread, and cautiously carried into the passage on a 
grooved director or along the finger ; enlarge the puncture by a crucial in- 
cision ; dilate with the end of the little finger ; pass the finger, or a bougie 
of suitable size, daily, for several months. 

Absence of the rectum may be partial, which is most common, or com- 
plete, the anus being normal. When only partially absent, the other portion 
usually terminates in a cul-de-sac at a greater or less distance from the sur- 
face of the body, or it may be prolonged as a narrow tube or imperforate cord, 
and blended with adjacent parts ; if wholly absent, the canal may open in some 
abnormal situation. The diagnosis is made by examination with the finger or 
a bougie. If the occlusion is not thick, it is only necessary to incise the in- 
tervening tissues and dilate. If the part is very thick and hard, dilate the 
anus, if necessary add lateral incisions ; separate the mucous membrane, and 
draw down the rectum ; cut off that portion including the septum, and attach 
the margin by suture to the skin. If the rectum is wholly absent and the 
bowel cannot be reached by dissection, a last resort is to make an artificial 
anus in the left groin. 

The Anus. 

Contraction of the anus may be due to a congenital narrowing of the 
lower part of the rectum and the anus, or of the anal orifice alone, or the in- 
tegument may extend partially over the anus ; the situation and form of the 
anus are generally normal, but the orifice is puckered or plicated ; the narrow- 
ing may be slight or only admit the passage of a probe. The symptoms are 
absence of meconium and progressive, painful tension of the abdomen, and 
vomiting. The treatment is dilatation : Select a graduated bougie, the tip of 
which readily passes the contraction ; inject a little oil to lubricate the parts ; 
or, if there are feces in the rectum, move the bowels first with an enema; 
place the patient on the back with the thighs well flexed ; warm and oil the 
bougie, and pass it gently but firmly into the constriction ; repeat the ope- 
ration, daily, until the part is enlarged to at least its normal calibre ; the 
finger may be substituted for the bougie when the stricture is sufficiently 
dilated. 

If the narrowing is extreme and very rigid and unvarying, incise the lateral 
surfaces on a director, and in the direction of the tuber ischii, to such a depth as to 



488 MALFORMATIONS AND DEFORMITIES. 

allow the passage of the feces ; if the first incisions are not sufficiently deep, repeat 
them ; but it is necessary to divide only slightly or partially the sphincter. If the 
narrowing is due to extension of the integument, incise it in several places on the 
director, and dilate daily with a bougie or with the little finger. 

Imperforate anus is generally caused by a lamina of fibro-cellular tissue, 
usually thin and transparent, permitting the meconium to be seen through it, 
and forming a small, roundish prominence, which is most distinct when the 
child cries or strains ; the bulging membrane gives to the finger a doughy 
feeling and sense of obscure fluctuation ; on pressure it recedes, but reappears 
on removal of the finger ; the membrane may be very thick and dense, espe- 
cially at the circumference, when the protrusion will be less prominent. The 
nature of the affection is apparent on inspection. If the membrane is thin, 
incise it at once ; if it is thick, and there is a doubt as to the continuation of 
the rectum, delay a day or two for the rectum to become distended; then, 
while the child is held on its back on the knees of an assistant, the thighs 
strongly flexed, make a crucial incision through the membrane, the point of 
intersection of the incisions being the centre of the anus ; remove the inter- 
vening flaps with scissors, and dilate the opening daily with the finger or a 
bougie. 

Absence of the anus is characterized by the obliteration of every trace 
of the orifice, the perineal raphe extending from the scrotum to the point of 
the coccyx without interruption, and the space of the anus being occupied 
with cellulo-fibrous tissue ; there are no external signs by which the location, 
or even existence, of the rectum can certainly be ascertained ; if it is present, 
and near the perineum, fluctuation may sometimes be detected by the finger in 
the perineum, or by pushing firmly up in the direction of the rectum, while 
with the left hand firm pressure is made upon the anterior walls of the abdo- 
men inward and down toward the finger in the perineum. If by these manip- 
ulations the presence of the rectum is detected, an operation will afford the 
desired relief. The patient being held by the assistant, as before described, 
and, if necessary, the sound introduced, make an incision in the median line 
from a point near the scrotum to the extremity of the coccyx (Fig, 101), 
through the skin and superficial fascia ; repeat the incision, but of gradually 
diminishing length, carefully feeling before each stroke to ascertain by fluctu- 
ation the presence of the blind sac of the rectum, and also the position of the 
bladder or vagina ; if the rectum is not found in the middle line, search pos- 
teriorly, as the extremity is sometimes displaced from the centre ; the bowel 
will be detected as a fluctuating tumor, more or less elastic, and of a dark- 
brown color ; when recognized, seize it with strong-toothed forceps, or pass 
a needle armed with a double ligature through it and gently draw it down- 

Fig. 101. Fig. 102. 



W 




Incision for imperforate anus. Bowel attached to external wound. 

ward ; adhesions may be broken up with the fingers, or the knife, or scissors ; 
when brought down to a level with the integument, open the cul-de-sac lon- 
gitudinally, empty its contents, thoroughly cleanse the part, and unite the 
margin, by six points of suture (Fig. 102), to the integument of the corre- 



THE URINARY BLADDER. 



489 



spending edges of the perineal wound in the exact situation of the anus ; the 
mucous membrane should overlap the external skin, to prevent the escape of 
fecal matters into the cellular tissue ; close the wound anteriorly and poste- 
riorly by suture ; bind the child's legs together with a bandage, and apply 
antiseptic dressings to the wound ; tendency to undue contraction must be 
counteracted by dilatation. 



CHAPTEE II. 



THE UKIXAKY BLADDER 



Extroversion of the bladder is a congenital malformation, occurring 
chiefly in males, in which the anterior portion and the parietes of the abdo- 
men are absent, so that the posterior and lower part of the bladder protrudes 
under the pressure of the viscera from behind as a round red tumor covered 
by mucous membrane, in which the orifice of the ureters can be seen. 

The linea alba bifurcates at the upper angle, but is continued on either side of 
the ossa pubis, forming a triangle 5 the pubic bones are not united by a symphysis ; 
the penis is small, the ureter and corpus spongiosum are deficient in their whole 
extent, and the only remnant of the urethra is a groove lined by mucous membrane 
on the dorsum of the penis ; the glans penis is full and large. 

This deformity leads to painful and distressing results, owing to the con- 
stant flow of urine over the groin and thighs, but it is in no respect danger- 
ous to life. The treatment may be palliative, by the application of an appa- 
ratus to collect the urine, of which there are many kinds. But even the best 
fitting does not always obviate the gradual soaking by the urine of the skin of 
the abdomen, groins, and perineum, and hence operations have been devised to 
relieve the disgusting deformity. Efforts have been made (1) to open com- 
munication between the ureters and the rectum, but the operation is very dan- 
gerous, and has not given satisfactory results ; (2) to cover the exposed sur- 
face ; some of these operations have been very successful, and have become 
legitimate by the approval of good authority. 

The following operations are advised : Make an umbilical flap, 1 (Fig. 106), 
and turn it down over the bladder ; then make two flaps from the groin, one 
on either side (Fig. 103), and slide them over the central flap, and attach them in 



Fig. 103. 



Fig. 104. 




Wood's operation for extroverted bladder 
outline of incisions. 




Wood's operation : flaps applied. 



490 



MALFORMATIONS AND DEFORMITIES. 



the median line (Fig. 104) ; the result is, the skin surface of the middle flap presents- 
to the bladder, and the raw surface is covered by the raw surfaces of the lateral 
the new wound is left to cicatrize. Or dissect off the mucous membrane of 



Fig. 305. 



Fig. 106. 




# 




Bigelow's operation. 

the exposed bladder ; make lateral flaps from both inguinal regions (Figs. 105, 106) ; 
unite them upon the median line and transversely above it, the points a, a, a, and 
b, b, being brought together, as the skin more readily yields in a direction obliquely 
upward ; the result is perfect (Fig. 106). 



CHAPTER III. 



THE EXTREMITIES. 



Fig. 107. 



The Upper Extremities. 

A supernumerary digit (Fig. 107) appears in many forms, and should be 
treated according to the peculiarities. (1) If it is attached loosely or by a 
narrow pedicle, divide the pedicle close to its point 
of attachment to the skin, so that no remains may 
be left ; hemorrhage must be carefully suppressed. 
(2) If it is more developed and articulates with the 
sides of the metacarpal or phalangeal bone which is 
common to it and another digit, operate early, and so 
arrange the incision as to leave as small a cicatrix as 
possible. (3) In cases where the additional digit is 
connected to the head of a phalangeal or metacarpal 
bone the removal is likely to involve the opening 
of the joint of the adjacent phalanx ; removal is 
advisable only in case the additional phalanx impairs 
the function of the other. (4) If the supernumerary 
digit is fully developed, having its own phalangeal and 
metacarpal bones, removal is rarely advisable, but if 
required must be taken away so as to leave as little 
deformity and impairment as possible. (5) There 
may be fusion of digits, or even of hands (Fig. 120), 
in which no operation is desirable. 




Supernumerary thumb. 



THE EXTREMITIES. 



491 



The union of digits, webbed, may be congenital, when it is generally sym- 
metrical ; or it may be the result of injuries and burns. The uniting medium 
may be the skin only, or the skin and deeper tissues, and even the bone. 
The two apposing digits may be united throughout their entire length or 
only in part. Webbed toes do not require treatment. When the union is 
partial and does not involve the interspace at the cleft, divide the connecting 

Fig. 108. Fig. 109. 





Apparent fusion of the hands. 



Seton inserted. 



tissue, and maintain the fingers apart until cicatrization is complete. When 
the union of the cleft is complete there is great difficulty in preventing reunion 
after division. Introduce a seton at the base of the cleft (Fig. 109) and allow 
it to remain until the opening becomes permanent, when the remainder of the 
web may be divided. India-rubber tubing introduced at the same point and 
tied to a band around the wrist makes a good seton. 

Make two flaps of the web, 
; for the posterior make an 

Fig. 110. 



If the septum is very dense, operate as follows 
anterior and posterior, but reversed (Figs. 110, 1-11] 



Fig. 111. 





Fig. 112. 




Diagram of flaps in operation for webbed finger, 
with thick septum. 



Operation for webbed finger : a, the lines 
of the two incisions uniting, so as to 
divide the web and leave a flap on each 
side ; b, the flaps detached from the op- 
posite fingers to those to which they 
are adherent ; c, the flaps applied to the 
fingers and covering in the raw and 
exposed surfaces (Erichsen). 



incision along the dorsal aspect of one finger the length of the web, and transverse 
incisions at either extremity to the middle of the dorsum of the other finger ; repeat 
the operation on the palmar surface, but make the longitudinal incision along the 
palmar surface of the finger which forms the base of the posterior flap ; dissect the 



492 



MALFORMATIONS AND DEFORMITIES. 



two flaps and turn them back 5 separate the fingers, which now have each a flap, one 
attached upon the dorsal and the other upon the palmar surface (Fig. 112) ; apply 
the flaps to their respective fingers ; the union of these flaps effectually separates the 
fingers. Maunder advises to separate the web along one finger, unite its margins, 
and thus form a flap for the apposed digit : close the wound left upon the other 
finger by a piece of skin transplanted from the hip, the hand being bound to the 
part until adhesion has taken place. 

Flexion of the phalangeal joints, so as to permanently distort the fingers, 
may be congenital or acquired. When the deformity can be overcome by 
division of contracted tendons or fascia, this operation must be performed 
and suitable splints applied. If, however, the conditions are unfavorable to 
tenotomy, the affected joint should be exsected. In extreme cases amputa- 
tion is the only successful remedy. 

The Knee. 

Genu valgum (knock-knee ; in-knee) is very common in children suf- 
fering from rickets. It is usually (Fig. 11-i) bilateral. Various opinions 
have been given by writers as to the precise local changes which take place. 
Formerly the deformity was believed to be due to a relaxation of the inter- 
nal lateral ligaments. Later, it was ascribed to an overgrowth of the internal 
condyle of the femurs. Recently, Humphrey has contended that the exter- 
nal condyle has ceased to grow as rapidly as the internal condyle, 
owing to undue pressure in bearing the weight of the body. The truth is, 
that these and other conditions exist in varying degrees. There is, pre- 
ceding the deformity at the knee, a noticeable weakness of the ankle and a 
disposition to a flat foot. This instability of the ankle and foot is due to 
impairment of the attachments of the ligaments to bones undergoing rachitic 
changes. The tendency of the foot would be to turn outward in walking, 
and thus change the bearing of the lower end of the femur upon the tibia 
in such manner that the weight of the body would fall most directly upon 
the outer condyle. The result would be diminished growth of the external 
and increased growth of the inner 

condyle of the femur. Noble Smith Fig. 114. 

(Surg, of Deformities) concludes from 
his examinations that the change is in 
the internal condyle of the tibia, and 
not in that of the femur. There is also 
a change in the axis of the femur, an 
inward curve forming in the lower third 
(Fig. 113), which, according to Mac- 
ewen. causes the internal condyle to 
descend still lower. In general, bilateral 
knock-knee is arrested before the knees 

Fig. 113. 





Extreme genu valgum (from a photo- 
Femur curved by rickets. graph). 

interfere with each other in walking, but in extreme cases they may pass each 



THE EXTREMITIES. 



493 



other. Instead of bilateral knock-knee, one knee may be valgus and the 
other bowed. 

Owen says : " The explanation of this association is from the mother carrying 
the child always on one arm. whilst she throws the other arm around the knees to 
make them fit into the hollow of her waist. Thus, if the child be carried always 
upon the left arm, the left leg will be valgus, while the right will be bowed.' ' 

In the early stages of this deformity it may be difficult to determine the 
fact of a commencing change. The most marked general symptom will be a 
complaint of fatigue and pains in the knee after exercise. If, now, the 
child is placed on the back, the internal condyles will be too prominent. If 
the knees are brought together, it will be noticed that the ankles do not 
readily touch, and the degree of separation shows the extent of the change 
at the knees. Attempts at adduction and abduction of the feet prove that 
the internal part of the joint is unnaturally lax and movable. 

The treatment will depend upon the stage of progress of the disease. 
When rickets is found to exist and the child is not walking, the tendency 
to knock-knee is so slight that no other precaution is required than to pro- 
tect the child from wrong positions, and by skilled massage, with forcible 
straightening of the leg, overcome any tendency to deformity. If, however, 
the deformity increases, a lateral splint, or two if both knees are involved, 
should be applied, which may be of wood and well padded so as to fit the 
leg. When applied it should extend from the hip to the foot along the 
outside of the limb (Fig. 115). The patient must not walk. The splint 
should be removed daily, and the limb rubbed, stretched, and compressed 
outward at the knee. By perseverance the deformity, if slight, may be 
overcome. 

If both knees are slightly valgus, Owen recommends that a flat pillow 
be fixed between the knees and the ankles tied together by a handkerchief 



Fig. 115. 



Fig. 116. 





Splint for knock-knee (Owen). 



Simple treatment of double 
knock-knee (Owen), 



or strap (Fig. 116) ; this method should be carried on day and night, and 
to prevent rotation of the tibiae a sand-bag may be kept across the knees. 

If the child is of a more advanced age, it may not be required to pre- 
vent the exercise of walking, but the necessity of proper support at the knees 
will be increased. An effective apparatus is that which is so arranged as to 
gently but firmly compress the inner surface of the knee outward to steel splints 



494 



MALFORMATIONS AND DEFORMITIES. 



having a joint at the knee and attached to shoes. Truehart has devised a very 

useful splint of this kind (Fig. 117). 

If the case appears as a confirmed knock-knee, and the child has recovered 

from the attack of rickets, the treatment assumes an altogether new character. 

We have then to consider the propriety of an 
Fig. 117. operation to correct the deformity. The methods 

now adopted, and the success which is assured, 
mark one of the great advances of modern sur- 
gery. Osteotomy as applied to the correction 
of genu valgum is an illustration of the great 
capabilities of antiseptic surgery. Though the 

Fig. 119. 



Fig. 118. 





a a, line of Ogton's in- 
cision ; bb, Reeves's ; 
b c, Macewen's. 




Apparatus for knock-knees. 



Drawing illustrating Dr. Ogston's ope- 
ration : right limb shows line of sec- 
tion of the inner condyle of the 
femur; left, inner condyle brought 
to required position (Bryant). 



knee-joint is to be entered directly with a rude instrument, either a saw or 
a chisel, the operation may be undertaken with comparative certainty of 
success. Barker and Owen have reported fatal cases, but with proper pre- 
cautions and antisepsis the chances are altogether favorable. 

There are several methods of procedure : Section of the internal condyle 
may be made with a view to its replacement and reunion on a higher level 
(Figs. 118 and 119). The condyle may be separated with a saw (Ogston) or 
with a chisel (Reeves). Section with a saw is much the more difficult opera- 
tion, but with antiseptic precaution it has proved very successful. The ope- 
ration with the saw is as follows : 

Flex the knee as far as possible and turn the thigh outward ; introduce a long 
and strong tenotome knife three and a half inches above the tip of the internal 
condyle on the inner side of the thigh, and as far back as the opposite ridge of 
bone running between the linea aspera and the condyle ; carry the blade forward, 
downward, and outward over the front of the femur, with its cutting edge directed 
to the bone ; when its point is felt under the skin, in the groove between the con- 
dyles where the patella would normally have been lying in the flexed position, 
divide the soft parts and periosteum by withdrawing the knife ; through the cut 
thus made introduce a narrow saw and divide the condyle nearly to the popliteal 
space ; now forcibly straighten the knee, and the remaining attachments of the con- 
dyle will be readily fractured (Fig. 119). 

Section with the chisel is free from the objections which apply to those 
methods involving a more or less free opening of the knee-joint: 



THE EXTREMITIES. 



495 



Introduce an antiseptic scalpel above the most prominent part of the internal 
tuberosity, and divide the soft parts and periosteum ; insert by the side of the knife 
an antiseptic chisel, and with a few strokes of the mallet penetrate the condyle to 
its greatest depth, but only as far as the cartilage covering it 5 the direction of the 
chisel should be first toward the intereondyloid groove, then the chisel should be 
partially withdrawn, and its direction altered forward and backward until the con- 
dyle is loosened, but not separated. Straighten the limb, breaking off the divided 
condyle, and pushing it upward with the head of the tibia (Fig. 119) ; close the in- 
cision, and apply an immovable apparatus, as gypsum, and retain it for three or four 
weeks in children, when passive motion must be begun and persevered in until the 
functions of the joint are completely restored. 

Macewen accomplishes the purpose by partly dividing, with a mallet and 
chisel, the femur at the base of the condyles, then fracturing it and straighten- 
ing the limb. He makes the incision at the base of the internal condyle 
(Fig. 120), but most operators prefer to operate from the outer side of the 



Fig. 120. 




Appearance of limbs before and after Macewen's operation. 

limb. Macewen's operation is the more simple, and, as the joint is not inter- 
fered with, it is the safer. The results are quite as good as Ogston's or 
Reeves's operation, as will be seen in the illustration (Fig. 120). 

Genu extrorsum (out-knee) is the result of a bending outward of the 
femur and tibia without inequality in the condyles of the femur. It may 
exist on one side and knock-knee on the other. In this case the knock-knee 
has caused the bow-leg by changing the axis of the trunk from its centre to 
the axis of the thigh of the affected limb. Out-knee is believed to be caused 
in many rachitic children by the position which they assume in sitting, with 
their legs abducted and rotated outward (Wright), the knees being unsup- 
ported. 

The treatment should protect the limbs from the weight of the body and 
from any position assumed by the child liable to increase the deformity, and 
at the same time existing curvatures should be overcome. While the general 
treatment for rickets is pursued, bathing in warm salt water, rubbing the 
entire body with the hands, and such manipulation of the curved bones as 
will tend to straighten them are very useful. In these efforts to straighten 
the bones no strain should be placed on the knee, lest the internal lateral liga- 
ments be weakened. All the force must be applied to the individual bone. 

If the deformity is firmly established and the child has recovered, osteot- 
omy must be practised with the usual antiseptic precautions. When out- 
knee is due chiefly to the bending of one bone, as the femur or tibia, it will 
be sufficient to straighten that bone (Fig. 113). But in the more marked 
cases both the femur and tibia must be straightened to secure the required 
results. 



496 



MALFORMATIONS AXD DEFORMITIES. 



The Leg. 

Bow-leg proper is a curvature of the tibia and fibula, without any change 
in the femur. It conies on insidiously, even before the child has begun to 

walk. The habit of sitting with the legs 
crossed, like a tailor, gives an inclination to 
the tibia. Wright states that if the feet 
are crossed one over the other, the curve 
will be most marked at the lower third of 
the tibia, and the leg which rests upon the 
other will have more of an anterior and less 
of an external curve (Fig. 121) than its 
fellow. 

The treatment must, as in instances 
already given, tend to prevent the deform- 
ity and correct those that have taken place. 
Bathing, rubbing, and straightening the 
/'/ / fim / *T| \\ affected bones must be persevered in until 

II ^&m ^SF \ t ^ ie cnnc ^ nas recovered. The mechanical 

LLmr ^^0 ^iy \3# appliances should maintain an equable pres- 

Bow-legs (Ashby and Wright). sure on the curvatures. Owen's apparatus 

is very useful and easily adjusted, as will 
be seen by the illustrations (Figs. 122, 123). A more expensive apparatus 
may be employed for children who are walking (Fig. 124). Two upright steel 




Fig. 122. 



Fig. 123. 



Fig. 124. 






Simple apparatus for bow -legs (Owen). 



Apparatus for rickets. 



stems are fastened below to a shoe and terminated above in the calf-band ; 
a leather bandage is passed around the stems and tightly laced in front over 
the arc of the curvature (or), or a strap is passed over the arc of the curva- 
ture and fastened to a spur suspended from the calf-band behind (c), the 
points of resistance being in either case the heel of the shoe (6) and the 
posterior trough of the calf-band (c). 

It should be borne in mind that after the child has recovered from rickets, 
and begun to resume active exercise, there is a strong tendency to the cor- 
rection of slight curvatures of the tibia, due to the action of the muscles. 
If, however, the curvature is great (Fig. 125) the tendency will rather be in 
the direction of increased deformity. The only radical cure of the latter 
cases is straightening the curved bones by osteotomy (Fig. 126). The ope- 
ration is very simple : 

Prepare the limb by washing and shaving, and irrigate the wound during the 



THE EXTREMITIES. 



497 



operation with the bichloride solution. Select an osteotomy chisel (Fig. 127) and 
mallet : make a longitudinal incision down to the bone with the scalpel ; now apply 



Fig. 125. 



Fig. 126. 




Result of osteotomy for bow- 




(Ashhurst) 



the cutting edge of the chisel transversely, and with repeated blows of the mallet 
nearly divide the bone ; then fracture the remaining portion ; ap- 
ply a catgut drain and close the wound with the continuous su- Fig. 127. 
ture ; straighten the limb, apply iodoform gauze, and finish with 
plaster-of-Paris dressing extending from the foot to the hip. 

The Feet. 

Distortions of the feet may be due to spasmodic action 
of one class of muscles, the antagonizing muscles acting 
normally, or to paralysis of one class, the opposing mus- 
cles being healthy. Careful examination of each case will 
determine whether spasm or paralysis is the cause ; but in 
general congenital cases are caused by spasm, and non-con- 
genital by paralysis. The general rule of treatment is to 
endeavor to overcome by appliances those deformities which 
readily yield to manipulation and are caused by paralysis, 
and to divide contracted tendons in those which do not yield 
readily and are caused by spasm. The object of treatment 
is the restoration of form and function, and the means to 
be employed are physiological, mechanical, and operative. 

Adams very justly remarks : " The scientific treatment of 
severe deformities can only be accomplished by a judicious 
combination of these three methods, and many of the failures are 
due to the want of this combination of principles too frequently 
considered antagonistic to each other." 

Selecting talipes-equino-varus, the most frequent ex- 
ample of club-foot, the rules of treatment as regards Macewen's chisel, 
the adoption of the several methods are as follows : (1) If 
no obstacle exists to the perfect restoration of form by gentle application of 
force, the defect may be remedied by the manipulations of the nurse, aided, 
in more marked cases if necessary, by simple mechanical appliances, as rub- 
ber plaster, a boot with springs. (2) If the foot can be nearly but not quite 
restored to its natural form by the hand, the heel remaining somewhat ele- 
vated so as to limit or prevent flexion at the ankle-joint, tenotomy is justi- 
32 



498 



MALFORMATIONS AM) DEFORMITIES. 



fiable, as it greatly hastens the cure. (3) In more severe grades tenotomy 
is indispensably necessary ; these cases are recognized by the following fea- 
tures : namely, the foot cannot be fully everted or brought to a straight line 
with the leg by manipulation, and in the attempt to effect this the inner 
malleolus does not become prominent. (4) The os calcis either cannot be 
depressed at all or only to a slight degree, so that after the partial ever- 
sion of the foot little or no flexion at the ankle-joint can be obtained. 

The following summary of principles of treatment of congenital club-foot, laid 
down by Little (of London), deserves attention : 1. Whether the case promises favor- 
ably for mechanical treatment only, or needs, as the majority of cases do need, ope- 
rative interference, commence the treatment as soon after birth as practicable. 2. 
Reduce the distortion from the state of a compound one (varus) to the simpler form 
(equinus) by first curing the inversion of the foot and the tendency to involution of 
the sole. 3. Avoid the slightest undue pressure upon prominent points of the leg 
and foot by careful padding of the hollow parts, and by using only gentle pressure 
with any bandage ; avoid obstruction of the returning blood from the limb. 4. Re- 
move splint and bandage daily, practise gentle movements of the foot in the desired 
direction, endeavor to prevent the part remaining for an instant unsupported and 
liable to fall back into the deformed position, until it is found that the foot, on re- 
moval of the bandage, retains a perfectly good position and flexibility. 5. Never 
permit the child to be placed on the feet or to walk until the form and movements 
are complete, whatever may be the age of the patient. The only apparatus neces- 
sary to carry out this treatment is a splint of tin or pasteboard so adapted to the 
external parts as to leave a space between the foot and splint when bandages are 
applied, or rubber plaster applied to the anterior part of the foot and passing up 



Talipes equinus (Fig. 128) is usually congenital. There are also vari- 
The treatment is operative and mechanical. The 



ous degrees of varus 



Fig. 128. 
Talipes Equinm 





G T1EMANN & CO 

Club-foot shoe. 



Congenital 

Club-foot. 

tendo Achillis and plantaris may alone require 
division, or, in addition, the plantar fascia 
must be cut, as when the arch of the foot 
is strongly contracted ; the foot should usually 
be brought into position at once and retained 
by splints or the gypsum dressing. In gen- 
eral it will be more advantageous; especially if the child is walking, to apply, 
within a week or two after the operation, the club-foot shoe. There are many 
varieties, as Sayre's, Shaffer's, Taylor's. The Sayre shoe (Fig. 129) generally 
gives satisfaction. 

Its construction and modes of action are as follows : A cushioned iron cap to 
receive the heel, the leather covering of which is carried over the instep and ankle 



THE EXTREMITIES. 



499 



and fastened by lacing ; elastic tubing, X, to go in front of the ankle-joint further 

to secure the heel in position, and fastening at C, 

an iron hook on outside of heel-cap ; sole of shoe, p -^q 

D. cushioned, and laced securely in front of the 

medio-tarsal articulation ; ball-and-socket joint, E, 

connecting sole with heel ; elevated plate of iron, 

F. properly cushioned, to make pressure against base 

of first metatarsal bone ; steel bars, G. connecting the 

shoe with strap, H, to go round the calf; joint, K, 

opposite the ankle ; stationary hooks, L, opposite 

the toes, for attaching the India-rubber muscles, 

3f. 31. M. These India-rubber tubes have chains 

attached, and are for the purpose of making flexion 

and eversion. 

Or the following more simple apparatus may be 
used : The sole of the strong leather shoe is of metal, 
with the joint near the heel, allowing lateral motion ; 
a durable spiral spring, a (Fig. 130), draws the foot 
outward by a constant, elastic, and easy traction ; 
this pressure is increased or decreased at will by 
fastening the spring in a series of sockets, c. The 
single outside upright steel bar, with joints at the 
ankle, is fastened round the limb below the knee- 
joint, and so constructed that the screw at the 
ankle-joint forces the foot flat upon the floor, 
the foot in almost all cases being turned under 
as indicated (Fig. 129) ; the spiral spring, d, at- 
tached to a catgut cord and fastened near the toes Club-foot apparatus, 
upon the outside of the foot, elevates the toes and 
stretches the tendo Achillis, thus drawing the foot to its natural position. 

Talipes calcaneus (Fig. 131) is both a congenital and non-congenital 
affection. In congenital cases the deformity consists in the position of the 




Fig. 131. 



Fig. 132. 





Acquired 

Congenital 
Talipes calcaneus. 

foot being an exaggerated degree of flexion, owing 
to paralysis of the calf. In acquired cases there 
is paralysis of the muscles of the calf and the exten- 
sors of the toes. In congenital cases the treatment 
required is passive exercise and the use of a soft 
padded splint applied in front of the leg and foot. If 
there is much contraction of the anterior muscles, 
the tendons of the tibialis anticus, extensor proprius pollicis, extensor lon-us 
aigitorum, and peroneus tertius may require to be divided. 

The apparatus has a steel spiral spring, placed on a pivot and playing between 
brackets of the leg and ankle-stem to depress the front part of the foot by e^en 
son ; there is not so much danger of falling with this apparatus when descending 
stairs. Or, instead of the spring, there may be an elastic band attached to the heel 
of he shoe below and to the ring above, which constantly tends to elevate the 



Shoe for calcaneus. 



500 



MALFORMATIONS AND DEFORMITIES. 



Non-congenital calcaneus is usually the result of infantile paralysis, and 
as a consequence tenotomy is seldom required ; palliative treatment alone 
must be attempted by the application of a proper shoe. 

Fig. 133. 
Congenital Varus. 




Club-foot— three grades of severity. 



Talipes varus, usually also equinus, in its severe form has the following 
external characters (Fig. 133) : namely, the anterior portion of the foot is 
turned inward, forming a right angle ; the sole looks directly backward and 
the dorsum forward ; the inner border looks directly upward and the outer 
directly downward. The first stage of treatment consists in correcting the 
varus by turning the foot outward into a straight position or by bringing the 
sole squarely downward ; the second stage consists in overcoming the eleva- 
tion of the heel, equinus, if that exist. If the foot can be brought around 
nearly straight with comparative ease, the effort should be made by manipu- 
lation and bandaging to correct the deformity. 

This may be effected by many methods : (1) Apply a strip of adhesive plaster 
around the anterior part of the foot, commencing on the dorsum and passing around 
the inside, then across the sole to 

the outside, and then, while the foot Fig. 134. Fig. 135. 

is turned strongly outward, up the 
outside of the leg to the knee : over 
this dressing apply a roller band- 
age ; repeat the dressing every sec- 
ond day (Fig. 134). (2)^ Apply a 
splint adapted to the outside of the 
limb (Little), with a foot-piece at an 
angle with the foot, and, beginning 
at the upper part, bandage the leg 
and foot to the splint (Fig. 135) ; 
change the dressing every second 
day, giving to the foot strong trac- 
tion externally. (3) Give the pa- 
tient chloroform, and, after forcing 
the foot outward fifteen minutes, 
apply a gypsum bandage (Ogston) ; 
repeat the dressing weekly. In 

cases which require tenotomy divide the tibialis anticus and posticus, and, if neces- 
sary, also the tendo Achillis and flexor longus digitorum ; after the healing of the 
wounds apply the club-foot shoe. 

The removal of a triangular mass from the tarsus (Colley) on the outside has 
been successfully practised in severe cases ; the steps of the operation and the 
results will be understood by the illustrations (Figs ; 136, 137, 138). Phelps has 
succeeded in overcoming severe forms of varus by incisions dividing all of the con- 
tracted tissues on the inside of the foot. These extensive operations are to be resorted 
to when milder methods have failed, and in older children. 

Hopkins of Philadelphia has recently successfully corrected inveterate 





Mode of stretching foot in 
talipes varus, by strapping. 



Varus treated by 
bandage. 



THE EXTREMITIES. 



501 



talipes varus by the artificial production of Pott's fracture deformity. He 
operated as follows : 

After tenotomy of the tendo Achillis, though the equinus element was almost 
absent, an incision two inches long was carried down to within half an inch of the 



Fig. 136. 



Fig. 137. 



Fig. 138. 




Foot before operation. Bones removed. Foot after operation (Bryant). 

external malleolus. The fibula, having been stripped of periosteum, was exposed 
and three-eighths of an inch of its shaft excised with cutting forceps, the lower 
section being three-fourths of an inch above the lower end of the bone. Forcible 
abduction of the foot brought the sole beneath and a little beyond. A few strands 



Fig. 139. 



Fig. 140. 





m 

The case before and after operation. 

of drainage were placed in the wound ; the limb was dressed antiseptically and 
placed upon an internal straight splint. A plaster-of-Paris dressing was applied 
fourteen days later, when a scanty serous oozing had ceased and the wounds were 
healed. The child showed no inflammatory reaction after the operation : indeed, 
none was to be expected, for the shaft of the fibula was not more than an eighth of 
an inch in diameter (Figs. 139, 140). 

Talipes valgus (Fig. 141) is rarely congenital. Marked cases, without 
rigid muscular contraction, may be cured mechanically in a few months with- 
out tenotomy, but severe cases demand a combination of operative, mechani- 
cal, and physiological means. The tendons requiring division in the slighter 



502 



MALFORMATIONS AND DEFORMITIES. 



cases are the peronei and extensor longus, and the tendo Achillis if involved ; 
in very severe cases the tibialis anticus and the extensor pollicis must also be 




Congenital 

Club-foot. 



Acquired 



divided. The mechanical treatment of slight cases in which the tendo 
Achillis is not divided is as follows : 

A convex pad of vulcanized India-rubber is placed inside of the boot in the 
normal situation of the arch of the foot which it is intended to support ; it should 
extend half way across the sole of the foot, and rise on the inner side so as to sup- 
port the navicular bone ; the heel should be raised on the inner side about a quarter 
of an inch, so as to twist the foot inward and throw the weight on the outer side. 
In more severe cases it is necessary to add a steel support, attached to the outer side 
of the boot and carried up to the calf of the leg, where it is connected with a semi- 
circular steel plate and a strap which encircles the leg ; a free joint should corre- 
spond with the ankle, and a leather strap attached to the inner side of the boot 
should pass across the ankle-joint and buckle outside the steel support. In the 
most severe cases, after tenotomy is performed a shoe must be applied which 
effectually brings the foot by degrees into position. The shoe and spring of Royal 
"Whitman are very effectual in accomplishing this result. 

Hollow club-foot (pes cavus) (Fig. 142), is due to paralysis of the inter- 
ossei muscles, the short flexor, and adductor of the great toe ; the first 
phalanges are extended upon the metatarsal bones, and the last two pha- 

Fig. 142. 




Hollow club-foot, pes cavus (Erichsen). 

laDges flexed upon the first; the posterior extremities of the first phalanges 
are subluxated upon the heads of the metatarsal bones ; then the curve of 
the plantar arch becomes increased and the plantar arch shortened ; then 
certain articulations and their ligaments become deformed as in all club-feet. 
From the position of the toes and from the increased arch of the foot the 
whole pressure in walking is borne upon the heel and upon the skin covering 



THE EXTREMITIES. 



503 



the unnaturally prominent heads of the metatarsal bones, which latter 
become tender in consequence, especially that over the great toe. The treat- 
ment consists in : 1. stimulation of paralyzed muscles by faradization ; 2, 
the division of the tendons of those muscles which their tonic contraction 
maintain and increase the deformity. The muscles more often divided are 
the extensor of the great toe, the tendo Achillis, and in addition a very 
tight band of the inner division of the plantar fascia. The Scarpa shoe may 
be used after the operation, having hinges across the middle and rack-and- 



Fig. 143. 



Fig. 144. 





Congenital hypertrophy of toes and foot. 
(Plantar aspect.) (Dorsal aspect.) 

pinion movement, so that the depressed heads of the metatarsal bones may 
be raised by the anterior half of the sole. 

Congenital hypertrophy of toes and foot (Figs. 143, 144) is occasionally 
met with. The only remedy is the adaptation of suitable apparatus to meet 
the deficiency of the foot. 



PART IV. 



SECTION I. 

DISEASES OF THE BLOOD. 

By Frederic M. Warner, M. D. 



CHAPTER I. 

MEL.ENA NEONATORUM. 

Hemorrhage from the gastro-intestinal surface occurs in children from 
various causes. It is a common symptom of intussusception in infants. It 
occurs from dysentery and purpura and from the syphilitic dyscrasia. It 
has been observed in polypus of the rectum and in anal fissures. In rare 
instances it occurs from the irritation of lumbrici, from foreign substances 
which have been swallowed, and from the ulceration of typhoid fever. Intes- 
tinal hemorrhage from such causes is a symptom of constitutional or local 
disease. But in newly-born infants it sometimes occurs without other symp- 
toms or without other appreciable disease, and therefore is regarded as an 
essential malady. 

Melaena neonatorum was mentioned by Storck in 1750, and various 
writers at different times alluded to it or briefly described it prior to 1825. 
It 1825 it was more fully treated of by Hesse than by any of his predeces- 
sors. 1 The monograph published by him was valuable, as it contained his 
own observations and those of contemporary physicians communicated to 
him, as well as the investigations of his predecessors. Dr. Kahn-Escher of 
Zurich (1835), Meisner (1838), Kiwisch (1841), Rumpe (1841), Hoffman 
(1842), and Helmbrecht (1843) published memoirs or related cases of 
melaena. Several of the best-known authors on diseases of children, long 
recognized as authorities in this branch of practice, have also written on 
intestinal hemorrhage, as Billard, Yogel, Eilliet and Barthez, Barrier, Bou- 
chut. West, Eustace Smith, and Goodhart, so that the literature of this dis- 
ease is no longer meagre. 

Age. — In the statistics of Billard, embracing 15 cases, 8 were between 
the ages of one and six days, 4 between the ages of six and eight days, and 
3 between the ages of ten and eighteen days. Of 20 cases embraced in the 
memoir of Rilliet and Barthez, 9 were at or under the age of thirty -six hours 
when the hemorrhage began. 5 between the ages of two and four days, 2 
1 Annalen von Pierer, 1825, Heft 6. 
504 



MELJSNA NEONATORUM. 505 

between six and eleven days, and 2 at the ages of fifteen and twenty weeks. 
Of 50 cases collated by Croom 1 from various sources, gastro-intestinal hem- 
orrhage took place in 30 between the first and sixth days, in 8 between the 
sixth and eighth days, in 4 between the eighth and twelfth days, and in 8 
between the twelfth and eighteenth days. The bleeding began in 6 within 
the first twenty-four hours. These statistics, which correspond with those 
of other observers, show that in a large majority of cases the hemorrhage 
occurs within the first twenty-four hours. Hsematemesis also takes place 
along with the intestinal hemorrhage in a considerable proportion of cases. 

Etiology. — The cause of melasna of the newly-born is involved in some 
obscurity. To a considerable extent the causes are the same as in hemor- 
rhage from the umbilicus, which we have treated of in a foregoing page. A 
predisposition to this and other forms of hemorrhage is sometimes inherited. 
Dr. Rahn-Escher states that the mothers sometimes have digestive ailments 
or other forms of ill-health, which he thinks produce atony of the vessels in 
their infants. The bleeding infant sometimes belongs to a family of bleeders 
and inherits hemophilia. In the Medical Times and Gazette for October, 1880, 
Dr. Croom relates 4 cases in which there appeared to be an hereditary tendency 
to bleeding. In 1 of the cases the father was subject to hemorrhages ; in 
another the pressure of the forceps produced extensive ecchymoses on both 
sides of the head. We have stated in our remarks on umbilical hemorrhage 
that newly-born infants affected by syphilis are very liable to intestinal 
and other forms of hemorrhage from the dyscrasia present or from anatomi- 
cal changes in the walls of the minute vessels, or, as is probable, from both 
causes. Our article on umbilical hemorrhage contains the statistics of 
Mracek. who at the autopsies of 160 syphilitic infants observed internal 
hemorrhages in 42, but in only 4 of these was extravasated blood present in 
the intestines. 

But the majority of the neonati who have gastro-intestinal hemorrhage 
do not appear to have any inherited dyscrasia or taint of system. Certainly 
the instances are exceptional in which the infants belong to families of 
" bleeders " or have the syphilitic dyscrasia. We must look for other causes 
apart from these. Billard attributes melsena of the newly-born to conges- 
tion of the vessels. Says he: " I have examined 15 cases of passive intes- 
tinal hemorrhage Most of them were remarkable for the plethoric 

condition of their bodies and the general congestion of their integuments, 
.... In all the large abdominal vessels, the liver, spleen, lungs, and heart 
were considerably engorged with blood." He adds : " It cannot be too 
strongly recommended to accoucheurs to allow the umbilical cord to bleed 
when a child is observed to be in a state of asphyxia ; for it has already 
been seen what serious effects follow from a superabundance of blood in 
young infants." 2 Vogel says : '.' The turgescence of the mesenteric arteries 
and their systems of capillaries, seen even in the physiological state, and 
produced by the sudden closure of the umbilical arteries, so important in 
the foetus, and which arise directly from the hypogastric arteries, may be 
looked upon as a cause of this disease. An especial thinness of the walls or 
friability of the affected system of vessels must certainly play a part here, 
because otherwise this, in reality, very rare form of hemorrhage would have 
to occur much more frequently. The closure of the ductus venosus Arantii, 
and especially that of the branch of the umbilical vein opening into the 
portal vein, deserves more frequent and stricter investigation to explain this 
hemorrhage." 

Rilliet and Barthez attach but little importance to the causes of melsena 
assigned by writers who preceded them, but state that it is easy to conceive 

1 Medical Times and Gaz., Oct., 1880. 2 Treatise on the Diseases of hi/ants. 



506 DISEASES OF THE BLOOD. 

that hyperemia of the intestinal tube, which is normal in the newly-born r 
might be increased by atony of the vessels or impeded abdominal circulation, 
through arrest of the circulation in the portal vein, so that hemorrhage 
would be likely to occur. Incomplete establishment of respiration, in which 
congestion of organs occurs, and especially of the intestines, they regard as 
a predisposing cause. They admit hereditary influence in certain cases, as 
when a parent has been subject to hemorrhage. M. Bouchut l makes three 
groups of cases of melsena, according to the supposed etiology, as follows : 
First, nielama from purpura ; second, from passive congestion, the result of 
compression at birth ; third, from acute or chronic inflammation of the gas- 
trointestinal surface. Dr. West believes that tedious and difficult labor, in 
which the head of the child is compressed and abdomen injured, is an occa- 
sional cause of intestinal hemorrhage. The tardy and difficult establishment 
of respiration he also thinks may be a predisposing cause, but he adds : " Very 
often no reason can be assigned for it." In two post-mortem examinations 
which he made no adequate cause was discovered. Braun 2 mentions among 
the probable causes congestion of mesenteric vessels, pressure during birth, 
heredity, intra-uterine malnutrition. Steiner 3 believes that intestinal hemor- 
rage occurs sometimes from a round perforating ulcer due to fatty degene- 
ration of the arteries. Hecker, Buhl, Spiegelberg, and Leopold Landau 
relate cases, six in all, in which abscesses or ulcers were observed in the 
stomach or duodenum, or in both. Landau expresses the opinion that these 
lesions occurring in the gastro-duodenal surface are produced by small embo- 
lisms. Keinhold 4 relates the case of an infant born May 15th who had 
hamiateniesis and melaena on the first day, and died May 17th. There was 
apparently epigastric tenderness. All the organs were ansemic. and the 
stomach contained seven or eight ulcers with edges slightly raised. No em- 
boli could be discovered, but the umbilical vein contained a brownish-red clot. 

On the other hand, J. Halliday Croom, lecturer on midwifery and dis- 
eases of women at the School of Medicine, Edinburgh, made the autopsy 
of a child that died of melsena at the age of half a day. The gastrointes- 
tinal surface was carefully examined, and no abscess, ulcer, or erosion was 
discovered, but some congestion was observed in the lower part of the intes- 
tine. He alludes to another case, described by Helmbrecht, in which the 
only apparent morbid condition was congestion of the rectum. In another 
case, observed by Dr. Croom, an infant of three weeks, previously well, died 
of haematemesis and melaena. Both auricles contained firm clots, and in the 
aorta was a clot partly decolorized. The only abnormal appearance in the 
digestive tract was capillary injection of the duodenal surface. 5 In a case 
reported by Schutze, 6 no ulceration of the intestinal mucous membrane was 
discovered at the autopsy, but the mouth, pharynx, oesophagus, trachea, 
stomach, bronchi, lower part of ileum, and larger intestine were full of a 
dark tea-colored fluid ; there were ecchymoses of the dura mater, and the 
lungs were emphysematous. 

Epstein of Prague 7 in an interesting monograph on melaena neonatorum 
states that hemorrhage occurs in the newly-born from various causes — from 
disturbance of the circulation leading to congestion, from disease of the ves- 
sels, and from disease of the blood itself. In infants born partly asphyxiated 
after tedious labor, or in weakly infants with atelectasis, Epstein says that 
hyperemia, hemorrhagic erosions, ulcerations, and actual hemorrhage of the 
gastro-intestinal surface are likely to occur. He believes that the most com- 

1 Traite pratique des Maladies des Nouveaux-nes. 

- Compendium des Kinderkeilkunde, Vienna, 1871. 3 Diseases of Children. 

4 Deutsche med. Woch., No. 28, 1881. 5 Medical Times and Gaz., Oct., 1880. 
6 Centralblattf. Gyndkol., No. 9, 1894. 7 Allgem. Wien. med. Zeit, No. 49, 1882. 



SIMPLE OB SECONDARY ANJEMIA. 507 

mon cause of nielaena is temporary congestion of the finer capillary vessels. 
When the surface of the stomach has been sprinkled with ecchymoses, small 
gastric ulcers have been present, caused by emboli in the gastro-duodenal 
vessels, resulting from thrombi in the umbilical vein. 

From the above quite numerous observations we are able to affirm that 
hemorrhage from the stomach and intestines in the newly-born occurs from 
different causes, prominent among which are — 1st, haemophilia ; 2d, inherited 
syphilis ; 3d, congestion of the gastro-intestinal surface ; 4th, ulcers occur- 
ring especially in the stomach, whether produced by emboli resulting from 
thrombosis in the umbilical vein or from other causes. 

Diagnosis. — If the infant vomit blood, the nipple of the mother or 
wet-nurse should be inspected, for a considerable amount of blood is some- 
times drawn by suction from the nipple. If no abrasion or sore be dis- 
covered upon or around the nipple or upon the lips or in the mouth of the 
infant, we may assume that hemorrhage is occurring from the stomach or 
upper part of the intestines of the infant. The presence of blood upon the 
diaper without any fissure upon the anus or external source of its occurrence 
is evidence of intestinal hemorrhage. The blood is dark and more or less 
changed by digestion or the action of the intestinal secretions if it have lain 
some time in the intestines. The pallor of the infant and increasing feeble- 
ness are evidence of the loss of blood. But in one instance myself and two 
other physicians were deceived by a midwife who had loosely ligated the 
umbilical cord, so that fatal hemorrhage occurred from it. The case was 
reported as one of intestinal hemorrhage, and was recorded as such in the 
statistics of the Health Board. The source of the hemorrhage was ascer- 
tained by a post-mortem examination which we were fortunate in obtaining. 
The gastro-intestinal surface was normal except its extreme bloodlessness 
and pallor. 

Prognosis.— The prognosis is in most instances unfavorable, but if the 
infant be strong and the amount of hemorrhage small, we may hold out some 
encouragement of a favorable result. It is possible, indeed, that a consider- 
able amount of blood may be lost and the infant recover. But weakly infants 
who have an abundant hemorrhage sink rapidly. If the bleeding do not cease 
in twenty-four hours, death will probably be the result. 

Treatment. — The child should be nourished at the breast if possible, 
and a little ice-water be given with a spoon along with the breast-milk. If 
the infant do not have breast-milk, peptonized milk may be employed. The 
food, of whatever kind, should be given cool. It has been recommended to 
apply the ice-bag over the abdomen while warm applications are made to the 
extremities. One grain of tannic or gallic acid dissolved in cool water may 
be given every hour, or one or two drops of turpentine. If the child exhibit 
signs of failing strength, a few drops of brandy should be given at short 
intervals in cold peptonized milk. 



CHAPTER II. 

SIMPLE OR SECONDARY ANEMIA. 

By simple anaemia we mean a condition resulting almost invariably as a 
consequence of previously existing disease, excepting, of course, post-hemor- 
rhagic anaemia, whereby the composition of the blood is greatly altered, re- 
sulting in the impoverishment of the vital fluid and the impairment of its 



508 DISEASES OF THE BLOOD. 

function. Should this condition be regarded as a symptom or as a disease? 
Unquestionably the latter, characterized as it is by certain anatomical appear- 
ances and a train of well-marked symptoms. 

In children simple anaemia is one of the most important pathological con- 
ditions we meet, frequently encountered, complicating many other states, in- 
fluencing other and grave diseases, always of much significance. In common 
with the other blood-diseases, it is characterized by a diminution in the amount 
of haemoglobin, which normally constitutes about 90 per cent, of the bulk of 
the red cells. The red blood-globules may be only slightly reduced in num- 
ber, they may even be numerically normal, and in very badly-nourished chil- 
dren there is a lessening in the whole amount of blood. 

Let us revert briefly to a consideration of the corpuscular elements of the 
blood, and the relationship of their state or condition to this affection. The 
red blood-cells are the means by which oxygen is carried to the tissues ; they 
vary in number from four and a half to five millions per cubic millimetre in 
the healthy adult ; at birth the number is greater ; within a short time it is 
rapidly reduced. (Plate III. Fig. 1.) 

Nucleated blood-cells, which are normally found in the red marrow, are 
probably intermediate between the red blood-cells and the marrow-cells ; these 
are not found in the blood of healthy adults, though present in the blood of 
children up to two or three years of age and in the foetus. According to 
Erlich, 1 they may be found in the blood of patients suffering from all varieties 
of anaemia ; they are a little larger than the ordinary red blood-cells and con- 
tain one or more nuclei. 

The white blood-corpuscles are larger and fewer than the red blood-cells 
in number, being about from eight to fifteen thousand per cubic millimetre 
normally, although this amount may be greatly increased without affecting 
the health. > 

The blood of children contains double and sometimes treble the adult 
number of white blood-cells, and in exceptional cases even a greater number, 
and then there is great likelihood that this condition of leukocytosis may be 
mistaken for leukaemia. 

Infants at the breast are said to have present in the blood a greater per- 
centage of leukocytes than those fed on cow's milk, Personally I have not 
been able to demonstrate this, although I have many times examined the blood 
of infants for the purpose of comparison. It is an undoubted fact that in all 
cases of anaemia the amount of haemoglobin is diminished, the sole exception 
being in pernicious anaemia, where the haemoglobin commonly equals or ex- 
ceeds the percentage of red blood-cells, and this may be demonstrated by 
means of the haemoglobinometer — an instrument which, as its name indicates, 
registers accurately the percentage of haemoglobin in the specimen of blood. 
The simplest instrument for practical use is the one devised by Gowers. 

In simple anaemia the percentage of haemoglobin is diminished to a much 
greater extent than that of the red blood-globules. (Plate III. Fig. 2.) 

In studying any of the blood diseases much may be learned by examina- 
tion of the blood — 1, for the haemoglobin as I have above suggested; and 
2, by the microscope, for a determination of the rough proportion between the red 
and white cells, their color, shape, and size, as well as those of the blood-plaques, 
the presence of nucleated blood-cells or of foreign bodies, such as the Plas- 
modium malarise. 

This latter method is simple, and is readily managed by any one with a 
microscope with ordinary lenses. For the more exact determination, how- 
ever, of the relation between the red and white corpuscles special apparatus 
is required. For this purpose the Thoma-Zeiss haemacytometer is in common 
1 Berliner klinische Wochenschrift, 1880, p. 405. 



PLATE 111. 



Fig. 1. 



Fig. 2. 




f®%®% 










or 



JP 



C 








Blood in Anaemia. 




o- o0 ° o 
n o°oOg°o 

co ° o°or° 

00 1 

o o°o O°0~ o 
M ° o J»©50o ( 





o 







Blood in Chlorosis, 
(x 300.) 



Blood in 

Acute Lymphatic Leukaemia. 

(x 300.) 



SIMPLE OR SECONDARY ANJEMIA. 509 

use. and is very simple and easily managed. It consists practically of a slide 
with a centrally depressed disk, which is divided into microscopic squares. 
Upon this surface properly diluted blood is dropped, the cells being counted 
within the given space, and as the dilution is a standard one, the total number 
of white and red corpuscles per cubic millimetre is easy to calculate. 

In various wasting diseases accompanied by great changes in the blood a 
condition is sometimes obtained in which marked alterations in the shapes of 
the red corpuscles occur ; they become variously distorted, and may even take 
upon themselves amoeboid movements. This is sometimes the case in simple 
anaemia, but is more characteristic of the condition known as pernicious 
anaemia. 

Etiology. — The causes which lead to the condition of simple anaemia in 
children are various, chief among them being malnutrition, secondary to graver 
diseases, such as scarlatina and inherited disease, tuberculosis, syphilis, im- 
proper and scanty food, faulty hygiene, including lack of fresh air ; and Haig, 1 
who has investigated this subject pretty thoroughly, thinks that severe anaemia 
is sometimes caused by a condition of uric-acidaemia. This I believe to be 
often the case. 

Rachford, 2 as the result of the examination of the blood of 166 school- 
girls, has been led to the conclusion that pronounced anaemia without apparent 
cause is strongly suggestive of concealed tuberculosis, and that anaemia in 
apparently non-tubercular girls coming from tubercular stock is very probably 
due to a deep-seated and hidden glandular tuberculosis. 

Symptoms. — We have seen that in anaemia — 1, the haemoglobin is reduced, 
and 2, the red blood-cells may or may not be diminished in number, while the 
total bulk of the blood may or may not remain practically the same. There- 
fore, the initial symptom to which our attention is apt to be called in this dis- 
ease is referable to this condition — pallor, ranging all the way from almost 
marble whiteness to dusky yellow ; pallor of skin ; pallor of all visible mucous 
surfaces ; certain portions of the body become markedly blanched, the ears, 
nose, and nails. 

In some cases the cheeks may be bright red in color, while the conjunctiva, 
the lips, gums, and roof of mouth betray a waxen whiteness. In other cases 
the temperature is normal ; in others an irregular pyrexia may develop, the 
pulse may be full and soft or small and weak, with the heart's action irregu- 
lar, while a venous hum may commonly be heard over the jugulars. Leu- 
korrhcea may develop in very young female children, and catarrh of the respi- 
ratory mucous membranes is of common occurrence. 

When the anaemia is secondary to and dependent upon other disease — 
such as rickets, for example — it is often the first symptom noticed. There is 
a peculiar puffiness of face, hands, and feet, resembling the oedema of acute 
Bright's disease. Patients complain of neuralgic pains, the most important 
and characteristic of which was first pointed out by Flint in cases of so-called 
spinal irritation, where pressure over the cervical and dorsal vertebrae causes 
intercostal and cervico-occipital pains, with perhaps the association of nausea, 
vomiting, palpitation, and a nervous cough. 

With these symptoms great weakness and prostration are of frequent occur- 
rence, associated with loss of appetite and obstinate constipation, which latter 
condition has been believed by Sir Andrew Clarke and some other observers to 
be one of the causes of the disease, by poisoning the patient from absorption 
of ptomaines from the impacted intestinal canal. 

Diagnosis. — The diagnosis must be made from chlorosis, pernicious 
anaemia, leukaemia, beginning pulmonary tuberculosis, and acute Bright's 
disease. 

1 Uric Acid, p. 218. 2 Transactions of the American Pediatric Society, 1S92. 



510 DISEASES OF THE BLOOD. 

From Chlorosis. — The age of the patient, as this is an exceedingly rare 
affection in young children ; also the hue of the skin in chlorotic patients is 
unmistakable, the typical greenish pallor — particularly true of brunettes — 
being entirely different from the yellow-white or muddy color of simple 
anaemia. (Plate III. Fig. 3.) 

From Pernicious Anaemia. — A microscopic examination of the blood in 
this latter condition is essential. The red blood-corpuscles are rapidly 
reduced in number ; they may reach only one-fifth or one-sixth of the nor- 
mal amount, while, on the other hand, the percentage of haemoglobin is 
relatively high. The red blood-cells are either much larger than normal or 
much smaller, and may take upon themselves irregular forms. Nucleated 
blood-cells are constantly present. The white blood-corpuscles are also 
diminished, but not to a corresponding degree with the red cells. 

From Leukaemia. — In the ansemia of infants leukocytosis is apt to occur, 
and it is due to this fact that errors in diagnosis are of common occurrence. 
The composition of the blood, however, is very characteristic. In leukaemia 
(a rare affection in infants) a constant, steady increase in the number of the 
white cells obtains, while there is a like steady decrease in the number of red 
cells. In leukocytosis the number of white blood-corpuscles varies greatly at 
different times. In leukaemia we have the enlarged liver, spleen, and lymph- 
atic glands, which of course are absent in anaemia, except in a form which 
has been described by Von Jaksch, 1 and which he calls anaemia infantum 
or pseudo-leukaemia. 

From Beginning Pulmonary Tuberculosis. — By means of the physical signs 
and characteristic range of temperature. 

From Acute Brighfs Disease. — By means of the presence or absence of 
casts and other symptoms marking this affection. 

Treatment. — In considering the treatment of this affection our object is 
primarily to increase the amount of haemoglobin contained in the blood. 
When the patient is the victim of inherited disease, syphilis or tuberculosis, 
medication appropriate to the systemic poison, together with the best possible 
hygienic conditions — fresh air, abundance of fatty food and expressed beef- 
juice (the nearest approach to the administration of haemoglobin at our com- 
mand), and regular exercise, preferably in the open air — will be of benefit. 
About the only two drugs which seem to be of efficacy in the treatment of 
anaemia in young children are iron and arsenic. 

Iron. — The blood of man contains one part of iron to two hundred and 
fifty parts of red blood-globules. In health a mixed diet contains sufficient 
iron for all purposes ; but when the percentage of haemoglobin falls below 
the normal amount, experience proves that the exhibition of iron in many 
cases promptly arrests this fall and restores the normal balance. 

Forchheimer 2 insists upon the intestinal tract as the principal place of 
origin of the haemoglobin, and believes that, excluding the origin of anaemias, 
the reduction of haemoglobin is due to either diminished formation, excessive 
destruction, or both. Therefore he treats all cases of simple anaemia, charac- 
terized, of course by a lessening of the amount of haemoglobin, by intestinal 
antiseptics. I believe that anaemias of intestinal origin, such as undoubtedly 
exist, may rationally be treated on this principle, but only those. The same 
observer believes that the good effect obtained by the employment of iron in 
anaemia is partly due to its ability to prevent the formation of albuminous 
products not compatible with haemoglobin formation. Be this as it may. the 
good effects produced in the treatment of anaemia with iron is too old a story 
to repeat, except to emphasize the fact of its value with a word of caution 

1 Annals of Universal Medical Science, 1890, vol. ii. pp. E. 12. 

2 "Ansemia in Children," Transactions of the Pediatric Society, vol. v. 



PRIMARY ANAEMIA. 511 

against its abuse. I believe that the best effects are obtained by the adminis- 
tration of small doses, for in this way it acts in the double capacity of a sto- 
machic tonic and a blood reconstructive. In large doses it quickly exhausts the 
gastric glands by over-stimulation, and it is then, of necessity, discontinued. 

Arsenic, in combination with iron or alone, in proportionately larger doses 
than adults will bear, is of great importance, and especially useful in chronic 
eases. It acts by increasing the appetite, promoting digestion, and improv- 
ing the body nutrition. In the anaemia of the uric-acid condition — which 
is. although of frequent occurrence in young children, commonly overlooked, 
and which may have resisted iron given in the usual way for a long time — 
brilliant results will sometimes be obtained by the administration of the 
salicylate of soda. 

Dr. Augustus Caille has published statistics regarding the value of the 
employment of inhalations of nascent ozone in the anaemia of children, which 
he deems considerable. I have used oxygen in a number of cases, and believe 
that it has been of service. Exercise in the open air, regularly, is probably 
equal in value with either. The treatment is therefore thus summed up : 
Eelieve, if possible, the constitutional cause of the anaemia ; in addition, 
give iron and arsenic sparingly, in tonic doses ; plenty of good nutritious 
food and systematic exercise in the open air. 






CHAPTER III. 
PKIMARY ANAEMIA. 

Leukaemia (Leucocythsemia), 

A disease characterized by a steadily progressive increase in the number 
of white blood-corpuscles, and a diminution in the number of red blood-cells. 
In many cases the spleen becomes very greatly increased in size, and in 
others the lymphatics become enlarged, and marked changes may take place 
in the bone-marrow. 

Etiology. — The origin of the disease is obscure. Tuberculosis, syphilis, 
malaria, anything which tends to seriously alter the bodily nutrition, predis- 
poses to the disease. According to the observations of Cameron (published 
in 1888) and those of Sanger (in 1891), intra-uterine transmission of leukaemia 
from mother to child does not take place. It is of rare occurrence in chil- 
dren, but is in many cases overlooked when actually present. It may follow 
the exanthemata. 

Morbid Anatomy. — The spleen is generally more or less enlarged in the 
splenic variety of the disease ; it may be so large as to seriously interfere 
with the functions of other organs. The lesions consist of a hyperplasia : on 
section the spleen is dark red in color, with occasional hemorrhagic infarc- 
tions. The lymphatic glands also undergo a hyperplasia, whitish or grayish- 
red on section ; the liver is generally large. The medulla of the bones may 
be gelatinous and red, or white from the number of leucocytes. The blood- 
changes are very marked. Normally, the proportion of white and red blood- 
cells is 1 to 500 ; in this disease the white cells may equal or exceed the red 
blood-cells in number. 

In acute lymphatic leuksemia the white cells are chiefly lymphocytes — 
small cells about the size of red blood-globules, nearly filled with a single 
nucleus. (Plate III., Fig. 4.) 



512 DISEASES OF THE BLOOD. 

In leuksemia linealis the colorless cells are much larger than the red 
blood-cells. In the splenic variety of the disease there are present large 
colorless cells, which do not occur in normal blood, and which differ from the 
other large white cells in the fact that they contain a fine granular mass in 
the nucleus. Blood-plaques may or may not be present. The Charcot-Neu- 
mann crystals readily separate out from the blood. (Plate IV. Fig. 1.) 

Symptoms. — The disease begins insidiously. The most characteristic 
symptoms are the blood-changes, aside from which occur extreme pallor, en- 
largement and tenderness of the spleen, enlargement of the lymphatic 
glands, in which caseation and suppuration may take place but rarely. 
When the disease affects the medulla there may be tenderness on pressure 
over the shafts of the long bones, over the sternum, and over the spinal 
column. Hemorrhages may occur from the gums and the nose frequently — 
haematemesis or haematuria rarely ; cerebral hemorrhage may take place. 
Nausea, vomiting, and diarrhoea are of constant occurrence. Jaundice and 
accumulation of fluid in the peritoneal and pleural cavities occur, and we 
have also the symptoms of anaemia — faintness, dizziness, and headache. A 
slight elevation of temperature is pretty constant, but at times it may be 
absent. 

Diagnosis. — An examination of the blood can alone reveal the presence 
of leukaemia, but this is characteristic and unmistakable. 

Prognosis. — A fatal termination is the rule ; exceptionally patients have 
recovered, but when this occurs a relapse after a longer or shorter time is to 
be looked for. 

Treatment. — Arsenic, iron, inhalations of oxygen, and in some cases, 
where seemingly indicated by an early history of malarial influences, quinine, 
are all, at times, of benefit, arsenic probably being of more real utility than 
any other drug. Pure air and good food are essential. There is seldom, 
however, prolonged benefit from any line of treatment. Excision of the 
spleen has been performed, but is not to be advised. 

Pseudo -leukaemia (Lymphatic Anaemia ; Hodgkin's Disease) 

consists in a hyperplasia of the lymphatic tissues wherever situated in the 
body, notably in the lymphatic glands and spleen ; frequently the liver is in- 
volved, associated with anaemia and pyrexia, and generally progressing to a 
fatal termination. 

Etiology. — Generally occurs during youth — very frequently, however, in 
childhood. A majority of the cases are in males. As a rule, the affection 
begins in an insidious manner from no assignable cause. It has been 
ascribed to syphilitic or tubercular antecedents. In other cases, however, 
local irritation, due to chronic disease of the ear, a decayed tooth, or naso- 
pharyngeal catarrh, gives rise to disease of the adjacent lymphatic glands, 
from which the glands in various parts of the body become affected. The 
main pathological change is an increase in the lymphatic tissue in various 
organs of the body. 

Morbid Anatomy. — The cervical glands are most frequently primarily 
involved, the axillary next, and then the inguinal. Of the deep glands, the 
thoracic, notably the bronchial, are most often enlarged. The glands, at 
first distinct, later become amalgamated into masses. The spleen is generally 
of large size, due to an increase in the lymphatic tissue, but this condition 
is not constant. The liver may be larger than normal, together with the 
kidney, due to the same lymphatic increase. The blood-changes are not 
constant. In the early stage of the affection there is no change ; later, how- 
ever, when the anaemia has become marked, the blood is characteristic of 



PLATE IV. 



Fig. 1. 



Fig. 









Bloocl in Leukaemia Lineal is. 
(x 400.) 



Chareot-Neumann Crystal? 
in Leuksemic Bloocl. 
(x 300.) 



Fig. 3. 




Bloocl in Pernicious Anaemia, 
(x 300.) 



PRIMARY ANEMIA. 513 

this condition, thin and watery, with a diminution in the number of red cells, 
the white corpuscles remaining at about the normal number. Occasionally 
the latter become greatly increased and true leuksemia may supervene. 

Symptoms. — The first symptom noticed is an enlargement of the cervical 
glands. They may remain in this condition unchanged for months or years, 
or they may grow larger rapidly, fusing together in great masses. At the 
same time the axillary glands increase in size, followed by the inguinal, these 
bodies taking upon themselves like changes. Glands deeply situated now 
become enlarged, as is demonstrated by the mechanical effects produced by 
the pressure of the larger veins upon the blood-vessels, bronchi, nerves, etc. 

Anaemia, intense and progressive, supervenes, associated with more or less 
fever and prostration ; pain, caused in part by poverty of the blood, in part 
by pressure on nerves ; constipation ; sometimes great difficulty in swallow- 
ing ; hoarseness, caused by pressure upon the larynx itself or upon the pneu- 
mogastric ; nausea and vomiting. 

Diagnosis. — This affection must be differentiated from tuberculous and 
scrofulous glands, from simple adenitis and leukaemia — from the two former 
by the family history, the course of the glandular enlargement in groups, 
then splenic enlargement, and the non-liability to suppuration ; from simple 
adenitis by the rapid subsidence of the latter under appropriate treatment ; 
and from leukaemia by an examination of the blood. 

Prognosis. — Lymphatic anasmia progresses almost always steadily to a 
fatal termination. Occasionally a case recovers, but it is the exception. The 
disease lasts from three months to three or four years. Cases have been 
reported of longer duration of the disease than this, but this, of course, 
depends upon the rapidity with which the lymphatic tissue increases, and 
whether the masses which are formed affect vital parts early or late. 

Treatment. — If the diagnosis is made early in the disease, extirpation 
of the glands affected gives the most hopeful chance for recovery. The 
usual tonic treatment of cod-liver oil, iron, and arsenic, as in most of the 
blood diseases, generally betters the condition somewhat. Salt-water baths, 
iodide of potassium, inunction of iodide of lead and lanolin, good diet, and 
fresh air are all useful. Pressure effects must be treated as occasion 
demands. 

Splenic Anaemia, 

an affection of which the essential factor is an enlargement of the spleen, 
associated with a waxen olive complexion. 

Etiology. — Enlargement of the spleen is of frequent occurrence in 
young children, and is generally caused, primarily, by syphilis, tuberculosis, 
malarial poisoning, and rachitis. 

Morbid Anatomy. — The principal pathological changes occur in the 
spleen, which is found to be large, smooth, and dense in consistency, red in 
color on section ; there is a hyperplasia of the fibrous tissue and a correspond- 
ing decrease in the amount of the normal adenoid substance. The number 
of red blood-cells is found to be greatly diminished, while the white blood- 
corpuscles in some cases are increased in number, and in others they remain 
about the same. 

Symptoms. — The peculiar pallor which accompanies this affection is often 
the first symptom noticed, and the large, smooth, firm mass appearing below 
the free border of the ribs and pushing out into the abdominal region, some- 
times occupying the whole of the left side. Vomiting and diarrhoea occur 
frequently in the course of the disease, diminishing the strength and lower- 
ing the vitality of the patient ; catarrhal troubles, notably bronchitis or 
broncho-pneumonia, often bring the case to a fatal termination. 
33 



514 DISEASES OF THE BLOOD. 

Diagnosis. — In all cases of anaemia in young children attention should 
be at once directed to the spleen ; the enlargement of this organ, from its 
position, mobility, hardness, and smoothness,, is not difficult of detection, 
while an examination of the blood, which should always be made in these 
cases, will seem to differentiate it from leukaemia. In pernicious anaemia the 
spleen is not particularly enlarged, and the disease differs essentially from 
lymphatic anaemia in that the glands are not affected and enlarged. 

Prognosis. — The prognosis of splenic anaemia or enlargement depends 
entirely upon the etiology. Tubercular and syphilitic cases are unfavorable, 
as are some cases of rachitic origin ; others, however, improve under good 
care. Malarial influences, which undoubtedly are the largest factors in 
producing this condition, usually yield readily to treatment and change of 
climate. 

Treatment. — The best results in the treatment of enlargement of the 
spleen will be obtained by the intelligent employment of drugs directed 
against the presumed cause of the disease, and sometimes brilliant results 
follow the use of mercurials in the syphilitic form, and quinine and arsenic 
in the malarial variety of the affection. In the rachitic and tubercular 
enlargements we may expect that attention to the diet and the hygiene 
of the little patient will achieve far more than the mere taking of any 
special remedy. The catarrhal affections complicating splenic anaemia may 
be best combated by suitable and warm clothing, and the patient must be 
kept out of doors as much as possible. Simple, easily-digested, or even 
predigested foods are indicated, and other complications must be treated as 
they arise. It is important, moreover, to sustain the patients to the fullest 
extent, and, after they have started on the road to recovery to guard against 
relapse, a not uncommon occurrence. 

Pernicious Anaemia (Anaemic Fever, Idiopathic Anaemia). 

This affection is characterized by anaemia, fever, and highly-colored 
urine, from excess of urobilin, together with marked changes in the blood. 
It is of rare occurrence in children. 

Morbid Anatomy. — The white blood-cells are diminished in number ; the 
red corpuscles are very greatly lessened ; they may be reduced to one-fifth or 
even less of the normal number, while the haemoglobin is relatively in- 
creased. The red blood-globules are very irregular, and may be much 
larger or much smaller in size, and may possess amoeboid movements. The 
blood may contain nucleated red blood-cells, which some observers consider to 
be pathognomonic ; the blood-plaques are fewer in number. Ecchymoses 
may occur. Fatty degeneration of the various internal organs — liver, kid- 
neys, etc. — is of common occurrence. 

Symptoms. — The skin is generally brown-tinted in color, and the mucous 
surfaces seem absolutely bloodless and of a pale leaden hue. (Plate IV. 
Fig. 3.) The pyrexia is not constantly present ; it may come and go. With 
these special symptoms are always associated those of simple anaemia. 

Etiology. — The cause of this disease is very obscure. In children it 
has been known to occur from no apparent predisposing element. It is more 
apt to result, following grave chronic gastro-intestinal disorders, constant liv- 
ing in-doors in rooms not often or well ventilated, and from insufficient and 
improper food. 

Treatment.— Arsenic seems to be the only drug of service in this affec- 
tion. Rest in bed, good, nourishing food, and attention to hygiene give the 
best results ; but in any case the outlook is unfavorable. 






PRIMARY ANJEMIA. 515 

Haemophilia, 

an hereditary affection characterized by the sudden development of more 
or less severe hemorrhages, either spontaneously or from slight cause. 

Etiology. — " Bleeders,'' as the subjects of this affection are called, are 
generally males, although females, while escaping themselves as a rule, most 
frequently transmit the inherited taint. For example, if a bleeder marries a 
healthy woman, the children generally remain free from the affection ; if, on 
the other hand, a healthy man marries a woman who is free herself, but who 
comes from a family of bleeders, the male children are generally bleeders. 

Anatomical Appearances. — No constant changes have been noted in 
this affection. Importance has been attached by some observers to a certain 
thinness of the blood-vessels. Probably, however, the chief morbid process 
will be found in the diminished power of the blood to coagulate. 

Symptoms. — The first symptom of the affection is sometimes discovered 
early in life from a fatal hemorrhage following the separation of the umbili- 
cal cord, but this is of rare occurrence. 

In other cases trifling cuts, bruises, knocks, or other injuries produce per- 
sistent hemorrhages, more or less serious in character according to the amount 
of blood lost. As simple an affair as the extraction of a tooth or an attack 
of epistaxis may result fatally. The hemorrhage is more often capillary, 
oozing generally from the bruised surface and presenting no vessel in par- 
ticular to tie. 

Diagnosis. — The diagnosis must be made from purpura by the history, 
and from scurvy by the absence of the given symptoms in addition. 

Prognosis. — The prognosis is always grave. Constant care must be 
taken to prevent injuries of all kinds, and no surgical operations must be 
performed upon these patients. 

Treatment. — The treatment is chiefly preventive, in not allowing the 
females to marry, in order to stamp out the disease. During an attack of the 
hemorrhage rest in bed, ice, and astringents may be employed. Ergot is said 
to be of service. Free purgation is advised ; iron and arsenic in full doses 
have been beneficial ; and in desperate cases transfusion is advocated. 

Purpura, 

an affection characterized by extravasations of blood, of greater or less 
extent, into the connective tissue beneath the skin, into the skin itself, and 
into the submucous tissue. Purpura may be simple and idiopathic or sec- 
ondary. 

Etiology. — Although the disease may occur in adult life, it is most fre- 
quently observed during infancy and childhood. It is probably due to the 
invasion of micro-organisms, and it may exist as the result of severe eruptive 
disorders, such as scarlatina, smallpox, measles, and typhoid fever. It is 
associated with haemophilia and scorbutus. Unsuitable food and unhygienic 
surroundings predispose to it ; rheumatism and grave gastro-enteritis and 
jaundice may be associated with it. It is frequently observed, chiefly around 
the eyes, accompanying the paroxysms of whooping cough. The administra- 
tion of certain drugs is followed in some instances by purpuric spots ; these 
are principally the iodide of potash, mercury, chloral, phosphorus, ergot, and 
belladonna. 

Anatomical Appearances. — In purpura there are extravasations of 
blood into the skin, subcutaneous tissue, and mucous and serous membranes. 
The loss of blood may in some cases be so serious as to result fatally. 

The cause is uncertain. Any place on the body may be the seat of the 



516 DISEASES OF THE BLOOD. 

purpuric spots, except in the rheumatic variety of the disease, when they are 
situated in the neighborhood of the joints. 

In purpura hemorrhagica hematuria may be the chief symptom. Hem- 
orrhage from the bowels and epistaxis frequently occur. The disease may 
assume the foudroyant character, terminating fatally within a few hours. 

Symptoms. — In simple purpura there may or may not be prodromata ; 
commonly there exists a slight rise in temperature, with pain and aching in 
the arms and legs, and occasionally nausea and vomiting. Then small pete- 
chial spots appear on various parts of the body, preferably upon the arms 
and legs, but also on the chest and abdomen, rarely upon the face. The 
buccal and conjunctival mucous membranes are favorite sites for these hem- 
orrhagic spots. They vary in size from a pin-point to an inch or more in 
diameter ; they may disappear in a few days, and reappear in successive 
crops. 

In the rheumatic variety, called poliosis rheumatica, there exist pain and 
tenderness of the joints — a decided arthritis — and occasionally an endocar- 
ditis, together with hemorrhagic spots associated with urticaria in the neigh- 
borhood of the affected joints. 

In purpura hemorrhagica, called also morbus maculosis Werlhofii, the hem- 
orrhages may be so severe as to cause death within a few hours or days. 
The disease commonly lasts, however, from two to four weeks, and relapses 
are of frequent occurrence. 

Profound anaemia sometimes results from the loss of blood, and hemor- 
rhages may occur from the lungs, kidneys, bowels, and stomach. Albumin 
may be present in the urine. 

Prognosis. — The prognosis is always favorable, except in the exceptional 
cases of purpura haeniorrhagica, when the disease suddenly ends with high 
fever and when the actual loss of blood is considerable. 

Diagnosis. — The diagnosis must be made from scorbutus, where the 
characteristic gums in children whose teeth have erupted and the previous 
history are the chief differential points, and from haemophilia, which is an 
hereditary constitutional condition. 

Treatment. — Perfect quiet in bed and symptomatic treatment according 
to the indications, together with a general effort to sustain the strength by 
nourishing food and to improve the quality of the blood by arsenic in full 
doses, rapidly pushed as high as possible, will give the best results ; nothing 
else seems to be of any avail. 

Scorbutus (Scurvy), 

a disease of which the essential points are a swollen and spongy condition 
of the gums, extravasations of blood into various parts of the body, pain 
on handling, and intense anaemia. 

Etiology. — In infants and children the causes of this affection are the 
same as in adults — dietetic. Scurvy is developed in those who are fed 
upon artificial foods prepared with milk and water or with water alone. The 
true cause of the disease is absence of fresh food from the daily regimen, 
and it is apt, from the nature of things, to be associated more or less with 
rickets. 

Scurvy seldom occurs in nursing infants, but in those who are taken from 
the breast and given patent foods or condensed milk and water, to the exclu- 
sion of fresh cow's milk and beef-juice ; in such the conditions exist for the 
occurrence of the disease. Cow's milk itself is an undoubted antiscorbutic, 
and it is only when it is given in small amount and much diluted that chil- 
dren receiving it are attacked by scurvy. 



PRIMARY AXjEMIA. 517 

Morbid Anatomy. — Extravasations of blood, varying in size from a 
pin-point to very large masses, may occur in any part of the body ; the most 
important of these is the subperiosteal hemorrhage which takes place 
between the shaft of one or more of the long bones, most commonly the 
femur, and the periosteum ; it may be so extensive that the membrane is 
detached from the bone through its entirety, retaining its connection only at 
the epiphyses ; the joints are never involved. The bone itself may become 
easily fractured, due to a softening of the osseous structure. Hemorrhages 
may also take place between the muscles or into the muscular tissue, into 
the various organs, and into the subcutaneous and submucous tissues. 

Symptoms — The first symptom of scurvy is generally the manifestation 
of ecchymoses, occurring quite suddenly in various parts of the body. In 
one of my own cases an extensive effusion of blood into the cellular tissue 
of the orbit first called attention to the child's condition. The production 
of pain upon handling, causing the child to scream whenever touched, calls 
attention to the lower extremities : one or both thighs or legs may be swollen 
and exquisitely sensitive to the touch, while the child lies immovable and 
cries with fear and apprehension whenever approached. This condition may 
exist also in the upper extremities, but more commonly in the lower. In 
the course of time the swelling begins to diminish and another extremity 
becomes affected. 

The gums are apt to be swollen and spongy, bleeding easily, especially 
if the teeth have erupted. 

As the disease progresses complications may be discovered at the extrem- 
ities of the limbs affected, due to separation of the epiphyses. The patient 
becomes profoundly cachectic. The rise in temperature, although generally 
constant, is, as a rule, not very high, rarely more than three degrees. 

When the case goes on to a favorable termination we find a gradual 
subsidence of all symptoms. The temperature drops ; the petechise dis- 
appear ; the pain, swelling, and tenderness over the long bones gradually 
diminish ; separated extremities unite ; and the color, strength, and appetite 
improve. 

Diagnosis. — In syphilis similar changes take place in the bones : if, how- 
ever, the other signs of syphilis are absent — viz. repeated miscarriage on the 
part of the mother, snuffles, hoarseness, condylomata, etc. — and if there be 
present spongy and swollen gums and evidences of localized hemorrhages in 
various parts of the body, the diagnosis is easily made. 

The differentiation from rickets is more difficult. In fact, these two dis- 
eases often coexist ; but the chief point of difference is that of great tender- 
ness and swelling over the long bones and not at the extremities. From 
symptoms the history is generally sufficient. 

Prognosis. — As a rule, patients recover from this condition rapidly after 
being put upon suitable food. Where the disease results fatally, it is on 
account of exhausted nutrition. 

Treatment. — The disease generally manifests itself between the first and 
second years as a result of the use of improper food after the child has been 
taken from the breast. We usually find these children being fed with one 
of the various prepared infants' foods or condensed milk and water. The 
diet should consist of fresh cow's milk, undiluted, unless it would be more 
easily digested by the addition of a little barley-water or rice-water or strained 
oatmeal ; beef-juice expressed from raw beef, freshly prepared, scraped beef; 
a raw egg beaten up with fresh milk, sweetened, with a little brandy added. 
Orange-juice should be given freely. It often causes marked improvement 
of the gums and other parts. 

In the way of medication the citrate of iron and quinine or the tincture 



518 DISEASES OF THE BLOOD. 

of iron, in conjunction with cod-liver oil or with cream and whiskey or brandy, 
are all that are necessary. 

Local applications of hot wet cloths may be made to the tender limbs, 
and when the epiphyses have separated the affected extremity must be 
placed in splints. 

The pain in the affected limbs may be so great that it will be necessary 
to administer an opiate. 



PART V. 

LOCAL DISEASES. 



SECTION I. 
INJURIES AND DISEASES OF THE OSSEOUS SYSTEM. 



CHAPTER I. 

CAKIES OF THE VERTEBRAE. 

Vertebral caries (Pott's disease) is of frequent occurrence in childhood. 
It is an ostitis of the bodies of one or more vertebrae, usually of tuberculous 
origin. It is more common in the city than in the country, where better 
hygienic conditions produce a more vigorous constitution. In some cases 
there is no apparent exciting cause, but generally there is the history of a 
fall upon or some injury of the spine. Caries may occur in the cervical, 
dorsal, or lumbar portions of the spinal column, but it is more common in 
the lower dorsal region than elsewhere. 

The pathological processes are those of tuberculous infection. The pro- 
cess is in the cancellous tissue of the vertebral centre, and the inflammation 
results in a cheesy metamorphosis, beginning in the interior of the mass 
of granulations and gradually extending in all directions. These deposits, 
chiefly situated in the anterior half of the bodies of the vertebrae, soften into 
a pus-like fluid, which escapes by stripping oft' the periosteum and the longi- 
tudinal ligaments of the column in front of which it accumulates, and then 
gravitates downward. The intervertebral disks cither escape the inflamma- 
tory changes altogether or become involved at a relatively late stage of the 
disease. The result of the disorganization is relaxation of the union be- 
tween the vertebrae, which favors dangerous displacements, as of the atlas, 
and angular curvatures in other regions of the spine. 

The disease begins very insidiously with obscure symptoms referable to 
the nerves of the affected region. If in the lumbar region, there are pains 
in the legs and hypogastrium ; if it originate in the dorsal region, the pains 
will be in the epigastrium, and are frequently treated as indications of stomach 
and bowel derangements ; if in the upper cervical region, the pains are in the 
chest or back of the neck and head. As the destructive ulceration progresses 
there is increasing weakness of the spine, with languor, inability to stand long- 
erect, avoidance of all jarring movements, and if the upper cervicals are 
diseased, a disposition to support and protect the head with the hands applied 
to the chin and occiput ; displacement in the form of a sharp posterior angle 
next appears, revealing positively the nature of the affection. Finally, pus 
gravitating from the affected vertebrae accumulates as a congestive abscess 
beneath Poupart's ligament or in the lumbar region. 

The diagnosis is often, from the nature of the disease, obscure and 
uncertain for a time. The long continuance of pain in the chest or abdo- 

519 



520 



LOCAL DISEASES. 



men. or perhaps in the thighs, without any cause which can be detected 
located at the seat of the pain, should excite suspicion of spinal disease. 
Such pain may be produced by spinal irritation, but in this malady pressure 
on the spine is badly tolerated, and when we touch a certain part the 
neuralgic pain is intensified. In caries firm pressure upon the spine is tole- 
rated, and it does not increase the neuralgia. At a later period in caries 
there are stiffness in the movements of the spine ; pain in the spine on 
sudden movement or jarring the body ; impaired appetite and general health ; 
and an instinctive desire to sit or recline in such a way as to relieve the spine 
partially of the weight of the head and shoulders. 

In the course of the examination undress the patient so as to completely 
expose the spine, and note any irregularities of the spinous processes. In 
infants, sitting, there is a uniform bending of the whole spine, which makes 
the spines prominent, but no one is markedly projecting ; this has been mis- 
taken for caries. Direct the patient to pick some article from the floor, which 
act reveals a stiffness of the spine. The patient inclines to sit down, rather 
than stoop, to avoid bending the spine (Fig. 145). If the disease is cervical, 
a slight tap on the head causes pain ; if it is dorsal or lumbar, the patient 
shrinks from rising on his toes and falling heavily on his heels. There is 
rarely any local pain or marked tenderness at the seat of the disease, except 
on percussion. 

When the disease is more advanced there is a prominent backward curve, 
a pendulous abdomen, and a slightly stooping attitude (Fig. 146). The most 
prominent spine always indicates the body of the vertebra originally involved. 



Fig. 145. 



Fig. 146. 





Early dorsal caries : child cannot bend the back in 
stooping, and supports weight by hand on knee. 



Attitude of child in angular cur- 
vature in advanced stage. 



The course of this malady, even when the caries is slight and the symp- 
toms mild, is tedious. In the most favorable cases the general health is but 
slightly impaired, the caries is confined to one vertebra, and is early diagnos- 
ticated and properly treated. On the other hand, if the general health be 
decidedly poor, the child anaemic and wasted, the curvature great, and an ab- 
scess have occurred, the case is very serious. Between these two extremes is 
every grade. 

The prognosis is more favorable in the child than in the adult. The few 



C ABIES OF THE VERTEBBJE. 



521 



adults whom I have seen with it all died. It is less favorable in the cervical 
region than in the dorsal or lumbar. A mild case occurring in a good con- 
dition of health may become grave, and even fatal, by neglect and improper 
treatment. A majority of the patients, if the disease be not too far advanced 
when recognized, recover if properly treated, but the deformity which results 
may prove serious in after-life. The incomplete expansion of the lungs in 
the humpbacked greatly increases the dyspnoea and the danger in subsequent 
years if bronchitis or pneumonia occur, and if the caries has been at a low 
point in the spine and the patient a female, the deformity will probably present 
an obstacle to childbearing. 

The treatment niust be constitutional and local, hygienic, medical, and 
mechanical. It is of the utmost importance to improve the general health, 
as it is in all chronic inflammation and scrofulous ailments. Pure air, sun- 
light, personal cleanliness, and plain but the most nutritious diet are required. 
Tonic and antistrumous remedies are indicated. It is advisable to give, three 
times daily, cod-liver oil, to which the syrup of the iodide of iron is added ; 
two or three drops of the latter to a child of one year, and one additional drop 
for each additional year. The judicious use of alcoholic stimulants will often 
be found serviceable if the appetite be poor and the general health seriously 
impaired, as will also the vegetable bitters. 

The mechanical treatment consists in applying such apparatus as will so 
support the upper part of the trunk that the pressure will be taken from the 
bodies of the diseased vertebrae. Of all the means yet employed, the plaster- 
of-Paris dressing is at once the most available and most efficient. It can be 
applied by every practitioner, and only requires a careful attention to the 
following details : 

Select crinoline or cheese-cloth for bandages, and a good quality of plaster of 
Paris, such as dentists use. Tear the crinoline into strips 1\ inches wide and 3 
yards long ; with a table-knife rub the plaster into the bandage as it is rolled, so 
that all the interstices are well filled, roll it up loosely 5 apply to the patient a tightly- 
fitting shirt of elastic, soft woven or knitted material, without arms, extending to 
the middle of the pelvis and fastened over the shoulder by tabs. Now have the 
patient's arms raised above the head and held in that position. The bandages, 
placed on the end in a basin of water until the bubbles cease to rise, are squeezed 
until the surplus water escapes, and then passed round and round the trunk, begin- 
ning at the smallest part, and extending downward a little beyond the crest of 

Fig. 148. 





Fenestra over curvature. 



Fenestra over stomach. 



the ilium, then upward in a spiral direction until the entire body is encased from 
the pelvis to the axillae ; pads of cotton are to be applied over any very prominent 
spinous process or other bony projection which maybe inflamed from previous pros- 
sure or liable to be irritated. The bandage should be placed smoothly, but not 



522 



LOCAL DISEASES. 



tightly, round the body, being simply unrolled with one hand and smoothed, so as- 
to be adapted to all the irregularities, by the other ; after one or two thicknesses 
have been applied, narrow strips of roughened tin or zinc should be placed on either 
side and parallel with the spinous processes, and others added at intervals of two or 
three inches until they surround the body ; over these apply other bandages. The 
patient must remain quiet in the recumbent position until the dressing is firm, when 
he may rise ; fenestras are often required at the curvature or where sinuses are 
discharging. 

If the diseased vertebras are in the lumbar or lower dorsal region, the 
bandage need not be applied higher than the axillae, but if the caries exist in 
the upper dorsal region, there must be additional support of the upper part 
of the thorax, and this is obtained by continuing the bandage over the shoul- 
ders, and thus encasing the entire trunk in the common dressing (Fig. 148). 
When this form is used the arms must not be in the sling, but should hang by 
the side. By this means the spine can be permanently maintained erect. When 
the caries attacks the cervicals, means must be used to so support the head 
that the contiguous vertebrse may not be compressed. This may be accom- 

Fig. 149. Fig. 150. Fig. 151. 






Plaster dressing for cervical caries. Jury-mast (Sayre). Apparatus for disease of cervical 

or upper dorsal spine : plaster 
jacket with "jury-mast." 

plished by supporting the chin or by lifting the head entire. The chin may be 
sustained by extending the plaster-of-Paris jacket upward as a cravat, well 
lined with cotton batting or other soft material (Fig. 149). Or the head may 
be raised entirely from the column by an appliance (Fig. 150) so incorpo- 
rated in the plaster bandage that it has a firm basis of support, and by a sling 
which accurately fits the chin and occiput and lifts the head directly upward 
(Fig. 151). 

To apply the apparatus the patient is suspended or lifted from the axillaa or 
chin and occiput, and the plaster bands applied, as usual, over a tight-fitting 
knit or woven shirt. After the bandage has been accurately applied, the patient 
is removed from the suspending apparatus and carefully laid upon a firm bed 
until the plaster has hardened or " set." The patient can then stand up, and the 
apparatus for suspending the head is applied in its proper position, over the back 
of the plaster Jacket, and the lower portion of it bent and moulded until it accu- 
rately fits all its various curves. The loose tin strips, being very flexible, can then 
be smoothly moulded around the jacket which has already been applied to the 
trunk, and another plaster bandage, having been wetted in water, is to be carefully 
and tightly applied over the apparatus and jacket first applied in sufficient number 
of layers to make it perfectly secure. The tin being rough and perforated, a suffi- 



CARIES OF THE VERTEBRA. 



523 



Fig. 152. 




Breast-plate and collar for cer- 
vical or high dorsal caries 
(Owen). 



cient amount of plaster will be incorporated into its holes and meshes to prevent 
any possibility of displacement. AVe have now a secure point of support from the 
pelvis and trunk, and the head can be sustained by 
properly adjusting the movable rod and securing it by 
screws (Fig. 151). 

While it is true that the jury-mast, well adjusted 
and maintained, usually gives good results, it is a 
somewhat troublesome apparatus to apply, and patients 
are occasionally intolerant of its use. More con- 
venient appliances, which equally support the head, 
may be employed. Owen of London recommends a 
simple apparatus. He says : 1 " I have given the jury- 
mast of Dr. Sayre a fair and extensive trial, and have 
now entirely discarded it. It is heavy and cumber- 
some, and offers no advantage over the leather cervical 
collar (Fig. 152), which bears up the chin and occiput. 
The rotary movement of the neck, which the jury- 
mast is constructed to permit, is an absolute disadvan- 
tage : rest, and always rest, is the one indication for 
treatment in all these cases. The cervical collar gives 
relief by ensuring this rest, rather than by lifting up the superimposed weight, as may 
be inferred from the fact that its influence is equally beneficial in high dorsal caries." 

The gypsum dressing may be worn without change from two weeks to two 
months, according to the effect which it produces ; when renewed the patient 
should be thoroughly washed, but without assuming the upright position, ex- 
cept when the head is well supported. The final cure is rarely completed in 
the most successful cases in one year. 

There are several kinds of useful apparatus for spinal caries more or less 
complicated in their mechanism, and requiring great experience and care in 
their successful management, but the plaster-of-Paris jacket is to be preferred 
on account of its efficiency, durability, and economy. 

A spinal brace may be so applied as to take the weight of the trunk above 
point of disease from the bodies of the vertebras and throw it on the articular 
cesses. There are two pieces or levers passing up the back, not over the spine, 
each side of it, so that it is firmly held from lateral devia- 
tions : to the upper end of these two curved pieces of steel 
are fastened diagonally on both sides of the neck ; they 
pass directly forward and around the shoulder, and thus 
prevent a great loss of force by diagonal action. The 
arrangement entirely obviates the painful and injurious 
ligaturing of the arms, which would occur if the straps 
passed forward from one point. At the part opposite the 
point of disease, the point where the fulcrum pads are 
placed is made of chamois skin or canton flannel, filled 
with cork filings, which have no felting qualities, or, if 
desirable, can also be made of hard rubber ; the shoulder- 
straps and the band around the hips are likewise pro- 
vided with similar pads to protect the skin from pressure 
and abrasion ; the instrument, like the spine itself, acts 
like a double lever, with a common fulcrum at the curva- 
ture ; this action is directly backward at the hips and 
shoulders and directly forward at the middle of the back, 
or wherever the diseased part is located; thus the pos- 
terior portion, the only healthy portion of the diseased 
vertebras, is made to support a part of the weight of the 
body, and the intervertebral cartilage and bodies of the 
vertebrae, where the disease exists, are relieved of pres- 
sure. The abdomen is still further sustained in the up- 
ward direction by an apron in front, which is fastened 
1 Surg. Dis. Children, p. 248. 



the 
pro- 
but 




Spinal brace (Taylor 
on each corner. If 



the 



524 LOCAL DISEASES. 

disease is in the upper dorsal or cervical region, an apparatus is constructed for 
such cases with an attachment for sustaining the head ; the effect and form of this 
attachment is that of a lever, acting backward to raise the head and neck. 

Spinal abscesses may find their way to the surface by very circuitous 
routes, and appear at unusual points quite unexpectedly. In general, how- 
ever, they appear as lumbar, iliac, or psoas abscesses. They should be opened 
antiseptically as soon as discovered. By delay in operating, especially on 
iliac abscesses, they increase in size, involve new areas, impair the general 
health, and constantly menace the life of the patient. By opening them no 
danger of suppuration is incurred as formerly, but, on the contrary, the gen- 
eral health is improved and the carious process may be arrested. Operate as 
follows : 

The surfaces having been well cleaned and shaved and the operator's hands 
being disinfected, under irrigation with bichloride solution, 1 : 1000, make a free 
incision through the overlying tissues into the abscess. If the abscess is iliac, the 
dissection must be more cautiously made. The cavity being exposed, cleanse it of 
all dead tissues and scrape off the granulations ; now explore the cavity, and if the 
sinus leading to dead bone can be found, gently pass a soft catheter along the track 
and carry it, if possible, to the abscess-cavity. Along that track it may be possible, 
especially in the lumbar and lower dorsal regions, to dissect a passage so as to give 
a full exposure of the carious vertebra and enable the operator to remove the dead 
bone and cleanse the cavity of all debris. If the carious cavity cannot be exposed, 
it may still be irrigated through the catheter, and the disease may be arrested. The 
abscess should be thoroughly washed out with a weak bichloride solution, ] : 5000, a 
drain-tube inserted, the wound closed, and iodoform dressings applied ; daily irri- 
gating of the entire cavity should be practised with disinfectants. 

Absorption of a spinal abscess may occur when the diseased vertebrae are 
maintained in a condition of perfect rest. 

Case (Owen *). — Lilian G , six years, came under treatment (in November, 

1880) for dorsi-lumbar caries, for which she was kept lying down for nine months, 
during which time night-shriekings and pains on movement disappeared. She was, 
as her mother said, " ever so much better." A plaster-of-Paris jacket was applied, 
which she wore continuously and with the greatest advantage for five months, gain- 
ing five pounds in weight. The next she wore six months, but on its being taken 
off the child complained of pains in the area of distribution of many of the cuta- 
neous branches of the right anterior crural nerve, and especially along the inner 
side of the ball of the great toe. Abscess was detected in the right iliac fossa. 
Another jacket was applied, and was worn continuously for fifteen and a half 
months ; on its removal there was not a trace of abscess, the child was free from 
pain, quite well, and strong. 

These abscesses may find their way into the intestines at different points 
from the duodenum to the anus, into the bladder, and in various localities on 
the surface in the region of the pelvis and thighs. 

In some cases, as in paraplegia, the operation of laminectomy has been 
performed, which consists in the excision of the laminae of two or three ver- 
tebras for the purpose of opening the canal of the spine and cleansing and 
curetting it. Macewen disapproves the operation while the tuberculous pro- 
cess is active in other organs, or when fracture has followed as a result of 
caries, or when paraplegia has suddenly appeared. The operation is as fol- 
lows (Power) : 

Place the child on the left side and make an incision over the projecting part of 
the spine ; separate the soft parts on each side and the periosteum of two or three 
vertebras ; divide the lamina of a vertebra with strong cutting forceps and twist it 
out of place. A second and third is removed in a similar manner, until the canal 
is sufficiently exposed. All tuberculous matter must be carefully removed. The 
cord and its sheath, lying along the anterior surface of the canal, must be gently 
1 Surg. Bis. Children, p. 247. 



LATERAL CURVATURES OF THE SPINE. 



525 



drawn one side -with broad retractors to permit of scraping away granulations. The 
cavity is to be swabbed with a solution of 1 : 15 zinc chloride, and then flushed with 
sterilized water of a temperature of 105°. The cord is replaced and pulsation 
looked for : the soft parts are united without drainage, the purpose being to obtain 
immediate union. 



CHAPTER II 



LATEEAL CUKVATUEES OF THE SPINE. 



Lateral curvatures occur in children who have suffered from 
rickets, and these deformities depend upon the period when they occur, 
whether before or after the child has commenced to walk. It must be re- 
membered that before the child has walked there is but a single curve of the 
entire spine — viz. posterior. The normal curves of the adult spine do not 
form until the child has been walking for some time. It follows that the 
rachitic curves of the spine which occur in a child, suffering from rickets 
before the period of walking, differ greatly from the curvatures which take 
place when the normal curves of the spine have formed. In the former case 
the curve is usually an exaggeration of the posterior curve of infancy, 
kyphosis (Fig. 154), or, there may be a simple lateral curve in any region 
of the spine, or, finally, there may be an anterior curve, lordosis (Fig. 
155). The posterior curvature of rickets is 

nearly uniform throughout the entire length Fig. 156. 

of the spinal column, and is distinguished 
from the normal curve by the inability of 
the child suffering from rickets to straighten 
its spine fully. The tendency is to sit with 



Fig. 154. 



Fig. 155. 






Kyphosis. 



Lordosis. 



Lateral curvature in a rickety child. 



the head falling forward (Fig. 156). If the child is placed on a flat surface, 
the curve will disappear. 



526 LOCAL DISEASES. 

When the curvature forms after the normal curves are perfected, the first 
deviation takes place in the lumbar region, usually to the left ; this is followed 
by a compensative curvature to the right in the dorsal region, and, finally, in 
severe cases, there is a cervical curvature to the left and forward. The initial 
deviation to the left is caused by a lateral inclination of the body to that side 
as the child sits or stands long in that position. Girls far more frequently than 
boys assume this attitude, owing to their comparatively sedentary habits. The 
secondary curve to the right is an effort to preserve the centre of gravity of the 
upper part of the body, while the cervical curve is designed to place the head in 
a similar position. In addition to these curves, true lateral curvature at later 
periods is attended with a partial rotation of the bodies on their axes. In 
the lumbar region the spinous processes are carried . around to the left ; in 
the dorsal region they are found far to the right of the centre. Another 
noticeable feature of this form of curvature, known as rotary lateral curva- 
ture, is the elevation of the left hip and right shoulder. These are diag- 
nostic signs of much value, and it not infrequently happens that the dress- 
maker first detects the curvature by the displacement of the scapula. 

AVhile the predisposing cause of curvature in these cases is rickets, the 
exciting cause will be any condition which temporarily deflects the spinal 
column. The position in which a nurse continually holds the child may give 
an improper inclination of the spine. In a similar manner a curvature may 
take place in older children who sit long in a one-sided position, as at school, 
or who have one leg shorter or weaker than the other, as in infantile paralysis. 
It is more frequent in girls than boys, owing chiefly to the fact that the 
former are more restricted in vigorous exercise, and hence have a less sym- 
metrically developed muscular system. The more quiet and sedentary life 
forced upon them in the formative period of the osseous system tends to 
enfeeble the muscles, and, at the same time, to induce postures of the body 
which cause deviations of the spinal axis. 

The diagnosis of lateral curvature of the spine in the child is of great 
importance, for it is at the very commencement of the deviation that the 

Fig. 157. 




From Hoffa. 



progress of the deformity may be arrested, and by very simple measures. 
In proportion as it progresses the changes of structure tend to become more 
and more permanent. It is advisable, therefore, always to make frequent 
examinations of the spine of a child that is passing through a course of treat- 



LATERAL CURVATURES OF THE SPINE. 



527 



merit for rickets. In this examination it must be remembered that the spine 
of the child, up to the time of walking, and oftentimes for a considerable 
period after, has not the ordinary curves of the adult spine. On the con- 
trary, the child has a uniform convexity of the spine backward, most marked 
when it is in a sitting posture, and more prominent in the dorsal region. The 
peculiarity of this curvature is — 1, that no one spinous process of a vertebra 
stands out abruptly from the two which articulate with it, as in angular 
curvature or Pott's disease ; and, 2, that there may be lateral inclinations of 
portions of the spine without disease when a child is feeble. An important 
fact in determining the existence of a curvature due to disease is this : if it 
is caused by disease, it will be unyielding in the movements of the spine. 
The best test is the following : If the child is laid on its face and its legs are 
raised, thus lifting the lower part of the body from the surface, the back be- 

Fig. 158. 




From Hoffa. 



be entirely exposed. Then 
the head to the sacrum by 

Fig. 159. 



comes concave if there is no permanent curvature, and all apparent devia- 
tions of the spine will at once disappear (Fig. 157). If, however, there is 
a permanent curve, as in angular curvature (Pott's disease), the curvature 
becomes even more prominent (Fig. 158). 

For proper examination the back should 
trace the course of the spinous processes from 
drawing the end of the finger along their tips. 
A red line is formed which shows the curva- 
tures if they exist. The ends of the spinous 
processes may also be marked with a pencil 
(Fig. 156) to make the line more distinct. If 
the patient now bend forward, the deformity 
becomes more marked. If lateral curvature 
is established, the chest-walls are also de- 
formed. There is a flattening on one side 
and a bulging on the other, which may be 
very prominent at the junction of the ribs and 
their cartilage (Fig. 159). 

The treatment of spinal curvature in 
a child suffering from rickets is twofold — viz. 
1. The general treatment, which should aim to 

restore the health of the child by measures already given ; and 2. The protec- 
tion of the spine from permanent curvature. If the child does not walk, care 




Section of chest, showing deformity 
consequent on lateral curvature 
(Shaw). 



528 



LOCAL DISEASES. 



should be taken to so change its position from time to time that no continuous 
curve of the spine can be maintained. If there is a tendency to antero-posterior 
curvature, the child should frequently be maintained in the prone position. 
In this position the weight of the upper portion of the body is, for the time, 
taken from the spine, and the curvature is completely reduced. Gentle rub- 
bing of the muscles of the spine, with the hands well oiled, increases their 
nutrition and growth. A light pasteboard splint may be applied to the back 
for short periods as a support to the spine, but must be employed onl}* tem- 
porarily. If the child is older and true lateral curvature is impending, the 
treatment must be modified only to meet the conditions which the ability to 
walk imposes. The general muscular system should be developed by mas- 
sage and such kinds of exercise as will tend to relieve the spinal column of 
the weight of the upper part of the body, as swinging from a bar, climbing 
a rope, lying prone and exercising the arms by stretching them above the 
head, and grasping handles to weights raised over pulleys. The question 
of applying apparatus is very important, and should always be regarded as 
an accessory and temporary expedient in the aid of the measures already 
described. In general it is better to avoid all apparatus in the early stages, 



Fig. 160. 



Fig. 161. 




Curvature before suspension (Sayre). 

and persistently apply those means which will de- 
velop strong and healthy muscles, and constantly 
guard the patient against assuming positions tend- 
ing to deflect the spine. When not engaged in 
suitable exercise it is better to recline on a sofa 
or in a chair, which takes the weight of the shoul- 
ders and head from the spine. The ordinary steamer- 
chair is well adapted for this purpose. 

If the child is older, and the deformity is already well advanced toward 
permanent rotary lateral curvature, the treatment must be governed by the 
condition of the patient when first brought under notice. If the distortion be 




Curvature removed by sus- 
pension (Sayre). 






LATERAL CURVATURES OF THE SPINE. 529 

aggravated by inequality in the length of the lower extremities, or owing to 
a congenital malformation, or to disease of the joints or fracture, thus caus- 
ing obliquity of the pelvis, the shortened limb must be artificially lengthened 
sufficiently to equalize the length of the two limbs before any other treat- 
ment can be effectual. If the deformity be caused by muscular debility or 
want of tone in the general system to keep the body erect, we must by 
proper training, gymnastic exercises, massage, nutritious diet, and tonics 
restore lost vitality and increase muscular power. Careless habits in sitting, 
walking, or standing must be guarded against and the vicious tendencies cor- 
rected. Extension of the spinal column by Sayre's apparatus is useful. 
This is affected by means of a leather collar passing under the chin and 
occiput, two straps passing from this up on either side of the head to an iron 
cross-bar secured by means of a rope and pulley to a hook or beam in the 
ceiling. The patient is expected to raise the arms over the head to their 
fullest extent, and, seizing the rope in the hands, commence to climb up hand 
over hand until the heels are gradually raised from the floor, barring the 
discomfort before this point may be reached ; the toes, however, should 
never leave the ground. The effect of this form of suspension upon the cur- 
vatures is very marked, as seen in the illustrations of the same person before 
and during suspension (Figs. 160 and 161). 

The hand on the side to which the concavity of the spine faces should always 
be the one uppermost when the patient has reached the height where the heels are 
raised from the floor (Fig. 161). While holding herself in this position the 
patient should take three full inspirations ; then slowly descend until she once more 
rests firmly on the floor, allowing the arms to fall by the sides and to rest there a few 
moments ; the same course is to be repeated, in all, three times ; for the greater 
convenience of holding on to the rope three or four wooden balls should be strung 
upon it and secured at a certain point after the patient has found out the limit of 
extension. It is necessary, in the performance of this partial self-suspension, that 
the patient should always keep the arm extended in a perfectly straight line, and 
simply make each hand go over the other, and no more, so that the muscles of the 
trunk, rather than the neck, may bear the strain. The apparatus for this purpose 
may be arranged in one's own room, and may be used for exercise night and morn- 
ing three times, as before described, until after some weeks, when the number of 
imposed tasks may be increased according to the hints already given. 

A very useful exercise is to stand in front of the patient while she is sitting 
upon a chair or stool, compelling her to turn and twist her trunk in the opposite 
direction in which the deformity exists, while you resist this movement. Another 
exercise is that of sitting upon a stool with the arm upon the concave side raised 
in front on a level with the thorax, while the arm upon the convex side of the 
deformity is placed behind the back ; then, seizing a rubber strap in either hand, 
the ends of which are secured to staples in the wall or door, the patient endeavors 
by muscular action to unwind, as it were, the rotation of the spine, and thus over- 
come the deformity. Suspension also may be made from two horizontal bars, as 
recommended by Adams, one being from two to four inches above the other — the 
hand upon the concave side of the curvature of the spine being the one to grasp 
the upper bar ; exercise upon these bars may be indulged in as often during the 
day as the patient may desire. Rings attached to ropes of unequal length effect 
the same object. Yet another exercise is to stand upon a block or box upon the 
foot of the convex side, and swing the leg upon the concave side, at the same time 
reaching upward with the arm of the same side as far as possible, the hand grasp- 
ing a weight of from two to four pounds, and while in this position to take three 
full inspirations. This also may be repeated several times daily. 

Sayre attaches great importance to the plaster-of-Paris jacket, applied 
while the vertebral column is extended (Fig. 161). The principles governing- 
its application have already been given. 



34 



530 LOCAL DISEASES. 

CHAPTER III. 

INJURIES OF BONES. 

The examination of a child that has been injured, for the purpose of 
determining the existence of a fracture, should be made in such manner as 
to secure its confidence. It is already suffering from the fright which the 
injury caused, and hence will be intensely excited at the approach of the 
surgeon. Hamilton's directions are admirable, and should be implicitly fol- 
lowed. He says : 

" It is important on first approaching a patient, especially a child, suffering 
from fracture, to inspire him with a confidence that he is not to be unnecessarily 
hurt : sit quietly beside hirn and inquire minutely into all the circumstances relat- 
ing to the accident ; remove the clothes from the injured limb with the utmost care ; 
notice its position, contour, points of abrasion, discoloration, or swelling ; pass the 
fingers lightly along the surface of the limb, pressing more firmly at points where 
there are appearances of injury ; finally, to solve all doubts, grasp the limb so as to 
make traction of the lower fragment, rotate to obtain crepitus, and make lateral 
motions to indicate the false point of motion ; in the application of the necessary 
dressings let gentleness and a manifest regard for the patient's sufferings character- 
ize every act, and throughout the subsequent treatment of the case proceed slowly, 
thoughtfully, and systematically, for rude and awkward manipulations, by which 
pain is needlessly inflicted, are frequent sources of inflammation, suppuration, and 
gangrene.*' 

In the treatment of the injuries of bones of children special care must be 
taken in their treatment. Children will not tolerate the same restrictions as 
the adult. Bandages around recently injured limbs must be avoided as far 
as possible ; splints should be protected by soft and yielding padding ; plaster- 
of-Paris dressings must be carefully watched. In restoring motion to stiffened 
joints after fracture the force used must be slight as compared with that 
which is proper in the adult. 

Injuries of the Skull. 

Depression of the bones of the skull without apparent fracture is most 
often seen in the parietal and frontal regions. It is the result of violence 
applied by a body which has a flat or a round surface. The bending is not 
unlike that which occurs in the long bones. Though the patient may be 
insensible from the immediate effects of the concussion, there are no indica- 
tions of compression, as paralysis. 

The diagnosis is readily made when the patient is seen immediately after 
the injury. But after a few days a hard ridge forms around the depressed 
area, which has often been mistaken for the limits of a fracture. 

The treatment should be rest and an application of a spirit lotion when 
there are no evidences of compression of the brain, as paralysis. The 
depressed bone gradually resumes its natural shape, chiefly owing to the 
pressure of the expanding brain underneath. 

Fractures of the skull in children require the same rules of treatment as 
in adults. 

Injuries of Long Bones. 

The long bones of children differ from those of the adult in these import- 
ant particulars: viz. 1, the epiphyses are united to the shafts by cartilage; 
2, the tissue of the bones is yielding ; and 3, the bones are liable to be im- 



INJURIES OF BONES. 531 

paired in their integrity by rickets. Owing to these peculiarities, injuries to 
the bones of children may result in three conditions rarely found in adult 
persons — viz. 1, separation of the epiphysis from the diaphysis (diastasis); 
2, bending ; 3, partial fracture (green-stick) ; 4, transverse fractures. 

The separation of the epiphysis is regarded by Holmes l as chiefly a frac- 
ture, for after the examination of a large number of specimens he states that 
the fracture occurs not very rarely at or in the immediate neighborhood of 
the epiphyseal line, and that the line of fracture coincides in these cases 
partially with that of the epiphyseal cartilage, but seldom completely. Chas- 
saignac and Marjolin had previously maintained the opinion that separation 
of the epiphysis strictly in the line of the cartilage rarely occurs. The 
chief importance of this fracture is the effect which it may have upon the 
future growth of the bone in length. It would follow that, if the result- 
ing inflammation should be attended by suppuration, the integrity of the 
uniting cartilage would be destroyed and the growth of the bone would be 
impaired ; or. if the cartilage quickly ossified, the growth of the bone would 
be arrested and deformity would result. 

Owen gives the following very judicious "general caution" in regard to frac- 
tures near a joint or through an epiphysis: " In every case of fracture near a joint 
or through an epiphysis it is desirable that the surgeon, however skilled and com- 
petent he may be, do not take the undivided responsibility of the case. Some un- 
toward event is apt to be associated with the injury which no exercise of art can 
with certainty avert. Thus, suppuration may occur and death follow from pyaemia ; 
or synostosis or other form of permanent stiffness may result ; or there may be some 
deformity : the humerus may fail to be properly developed, and the limb may be less 
useful than was anticipated. Over the result of the treatment of injuries near a 
joint, skilful as it may have been, great unpleasantness is apt to ensue. See that 
the parents should be made at once to thoroughly understand the serious nature of 
the injury, at least as regards the future effect ; they should not be caused needless 
alarm, but should see the advisability of adopting precautions. A shoulder or 
elbow left permanently stiff may wellnigh ruin a professional reputation ; its ex- 
istence is never forgotten. In every country village some brother-practitioner can 
and should be found to help with anaesthetic and counsel. If, when all swelling 
has subsided, union be taking place with some deformity, the surgeon should think 
twice before breaking it down with the idea of resetting the bone. Such inter- 
ference might result in fracture of the bone in a fresh place, or might be followed 
by serious local disturbance." 

The diagnosis of epiphyseal separation is often diflicult, owing to its 
proximity to a joint and the absence of crepitus. It is often mistaken for a 
dislocation, and efforts are made at reduction. These mistakes are most fre- 
quent at the upper and lower extremities of the humerus. An error can be 
avoided by giving especial attention to the fact that the deformity can be 
overcome with ease compared with a dislocation, and that when the apparent 
dislocation is reduced the deformity recurs when traction ceases. Moreover, 
the head of the bone will be found in the joint. These signs determine the 
fact that there is a lesion of the bone, while the absence of crepitus and the 
proximity of the joint prove that the condition is neither a fracture nor a 
dislocation. The logical conclusion must be that there is a separation of the 
epiphysis. 

The treatment of this form of injury does not differ materially from 
that of a complete fracture. Every possible effort should be made to place 
the fragments in complete apposition in order to secure perfect union. When 
the separation is reduced the ordinary dressings for fracture at the same 
point are indicated. 

The bending of the long bones of children occurs at an early period. The 

1 Surg. Treatment of Children' s Diseases. 



532 LOCAL DISEASES. 

accident is not frequently alluded to by writers, because the bone usually 
quickly recovers its former position, and Hamilton's experiments prove con- 
clusively the possibility of the bending, but quick recovery, of the long bones 
of the young. They also show that if the bent position continues there has 
been a partial fracture. 

Partial fracture occurs when on one side, the convex, a fracture takes 
place involving only the surface, while on the opposite side, the concave, there 
is an impaction of tissue. It is most frequently seen in the clavicle. In 
some cases the bone undoubtedly recovers very nearly its normal position 
when the violence is removed. 

Case (Hamilton). — An infant boy, three years old, fell from the hands of the 
nurse. The child cried, but the point of injury was not detected until the third or 
fourth day, although the mother examined the shoulders and neck carefully at the 
time. She is quite certain that if any swelling or discoloration had been present 
she would have seen it then or on the subsequent days while washing and dressing 
the child. When first seen it was very distinct, but not so large as at present. 
Seven days later the child was brought to me. A little to the sternal side of the 
middle of the right clavicle there was an oblong node-like swelling, of the size of 
the half of a pigeon's egg, hard, smooth, and feeling like bone ; there was no dis- 
coloration or swelling of the integuments; no crepitus or motion; the line of the 
clavicle seemed nearly or quite unchanged. 

The only evidence which remains of a previous fracture is a subsequent 
nodule which forms at the seat of the lesion of the bone. 

In the treatment of these forms of injury it must be remembered that 
there is a constant tendency to a recovery of the proper position. In bend- 
ing and in partial fracture with slight displacement there is, therefore, no other 
treatment required than protection from further injury. Moderate efforts may 
be made, under chloroform, by pressure of the fingers on the convexity of the 
bone, to restore its position, but care must be taken not to make such strong 
compression as will produce a complete fracture. A sling for the arm of the 
side on which the clavicle is fractured ; a splint on the concave side of the 
arm ; one on the anterior and one on the posterior surface of the bent fore- 
arm ; a splint on the concave surface of the bent femur, the interior surface 
of the leg, in which the fibula is bent, — comprises the treatment of the cases 
which will come under the care of the practitioner. 

Hamilton remarks : " But we need not be over-anxious to straighten the bone 
completely, since experience has shown that after the lapse of a few weeks or months 
the natural form is usually restored spontaneously. I am not now speaking of those 
cases in which the restoration occurs immediately, in which it is probable that the 
splintered fibres offer no resistance to the restoration, but only of those in which the 
bone straightens so gradually as to induce a belief that the broken ends are tha 
cause of the resistance. In a case mentioned by Gulliver it required about four 
weeks' time to render the bones of the forearm perfectly straight ; and in one case 
mentioned by Jurine at the end of six months it was ' difficult to say which arm 
had been broken, and at the end of one year it was impossible.' " 

Fractures in the new-born may have occurred in utero or at the time of 
birth. They represent all of the peculiarities seen in the fractures of tho 
child in early life. 

Case. — A woman in the sixth month of pregnancy was injured in the abdomen by 
striking against a table. Her child had a separation of the lower epiphysis of the 
tibia. The end of the shaft had perforated the skin and was necrosed. 

Simple bendings of bones are met with at birth, and simple fractured 
bones which have united with deformity. Even compound fractures in utero,. 
which have united before birth, have been reported. 



INJUEIES OF BONES. 



533 



Case. — Proudfoot of New York has related a case of compound fracture in utero 

which was apparently caused by external violence. Mrs. F , during the sixth 

month of gestation, while attempting to pass through a very narrow passage, was 
severely pressed upon the abdomen, and immediately experienced a severe pain in that 
region, accompanied with nausea and faintness. The following day uterine hemor- 
rhage, with pain, commenced, and these symptoms continued at intervals, in a form 
more or less severe, up to the period of her delivery, which occurred at full time and 
was perfectly natural. At birth the right foot of the child, a female, was found to be 
much distorted and in a condition of valgus with equinus, the outer side of the foot 
being laid against the side of the leg above the external malleolus. The tibia also 
of the same limb, near its middle, seemed to have been the seat of a compound frac- 
ture, the two ends of the bone having united at an angle slightly salient anteriorly, 
and the skin presenting over the point of fracture an old cicatrix. 1 

The treatment of these forms of injury is to be conducted on the same 
principles as in children. It will often be difficult to adapt suitable splints to 
the child's limbs and retain restrictive dressings, but very thin and light paste- 
board splints, well padded, can be employed and retained by bandages or 
rubber plasters, care being taken that they are not too tightly applied. 

The clavicle is more frequently bent or fractured in children than any 
other long bone. This is due to the frequency of their falling upon the 
shoulder and the several curves of that bone. The indications of treatment 
are to place the shoulder in a position upward, backward, and outward. In very 
young children a sling, supporting the elbow and arm, is the best appliance. 
Recovery occurs in most cases with but little deformity. In older children 
the adhesive strip of Sayre secures the position of the arm most effectually. 

Select strong adhesive plaster, and cut it into two strips three or four inches 
wide, but narrower for children ; one should be of length to encircle the arm and 
the body, and the other to reach from the sound shoulder around the elbow of the 
fractured side and back to the place of starting. Pass the first piece around the 
arm just below the axillary margin, and stitch in the form of a loop sufficiently 
large to prevent strangulation, leaving a large portion on the back of the arm 
uncased by the plaster ; draw the arm downward and backward until the clavicular 
portion of the pectoralis major muscle is put sufficiently on the stretch to overcome 



Fig. 162. 



Fig. 163. 




First adhesive strip. 




Second adhesive strip. 



the stern o-cleido-mastoid, and thus pull the inner portion of the clavicle down to 
its level ; carry the plaster smoothly and completely around the body, and pin to 
itself on the back to prevent slipping (Fig. 162). This first strip of plaster fulfils 
a double purpose : first, by putting the clavicular portion of the pectoralis major 

1 New York Journal of Medicine, 1846. 



534 



LOCAL DISEASES. 



muscle on the stretch, it prevents the clavicle from riding upward ; and. secondly, 
acting as a fulcrum at the centre of the arm when the elbow is pressed downward, 
forward, and inward, it necessarily forces the other extremity of the humerus (and 
with it the shoulder) upward, outward, and backward. And it is kept in this 
position by a second strip of plaster, which is applied as follows : Commencing on 
the front of the shoulder of the sound side, draw it smoothly and diagonally across 
the back to the elbow of the fractured side, where a slit is made in its middle to 
receive the projecting olecranon. Before applying this plaster to the elbow an 
assistant should press the elbow well forward and inward and retain it there, while 
the plaster is continued over the elbow and forearm, pressing the latter close to the 
chest and securing the hand near the opposite nipple : crossing the shoulder at the 
place of beginning, it is there secured by two or three pins. 

The humerus may be fractured at many points, but those most frequent 
and important in children are separation of the epiphyses and fractures at the 

elbow-joint. Separation of the upper epiphysis 
(Fig. 164) is recognized by the location of the false 
point of motion, absence of crepitus, and the pres- 
ence of the head in its proper position. It is most 
frequent on the right side. When separation of 
the lower epiphysis occurs, the elbow has the ap- 
pearance of a dislocation backward of the ulna, but 
its easy reduction and the return of the dislocation 
without any spreading of the joint, as occurs in 
separation of the condyle, determines its nature. 

Fractures at the elbow are as follows : At base 
of condyles, often difficult of diagnosis, owing to 
swelling ; most reliable signs are mobility, crepitus ; 
easy reduction, but immediate return of deformity ; 
great prominence of olecranon, like a dislocation ; 
pronation of hand. At the base of the condyles, 
with longitudinal fracture between them, some- 
times comminuted ; this fracture has the same 
symptoms as the last, with widening of joint and 
crepitus of condyles. Fracture of either condyle 
is known by separate movement of the condyle. Separation of epicondyles 
is detected by grasping the fragments. 

Fractures of the arm at all points are best treated in children by a gutter 

splint extending from the shoulder to the 
hand in order to preserve absolute rest. 

Select a piece of light felt or binder's 
board long enough to extend from above the 
acromion process to the hand, and wide enough 
to enclose about one-half of the circum- 
ference of the limb; cut it partially down on 
each side at the elbow, so as to bend it at a 
right angle : mould it while wet to the outside 
of the arm and forearm, and allow it to become 
dry : protect the splint with cotton-wool : re- 
duce the fracture and apply the splint with a 
roller bandage. In case of separation of the 
upper epiphysis a cotton-wool pad should be 
placed in the axilla. If the fracture is at or 
near the elbow-joint, place the forearm at a 
right angle with the humerus, and maintain it 
Dressing of fractured humerus. in this position by a right-angled splint, well 

covered with a woollen or cotton sack, and se- 
cure it to the forearm by a roller. The front or bend of the elbow should always 
be well covered with cotton batting before enclosing the elbow-joint in the turns 




Humerus, shaft, epiphyses, and 
inner condyle detached. 



Fig. 165. 




INJURIES OF BONES. 



535 






of the roller, to prevent strangulation. Passive motion must be commenced in about 
two weeks by loosening the dressing, supporting the parts thoroughly at the joint, 
and making slight flexion and extension : repeat this manoeuvre occasionally. 

The ulna may be fractured in any part of its shaft by direct violence ; the 
diagnosis is readily made. The treatment is by lateral splints of thin paste- 
board, the bones being maintained parallel and separated by small pads on the 
anterior and posterior aspect ; the splints should be wider than the arm, and 
be retained in position by two adhesive strips, one near the elbow and the 
other near the wrist, passed completely around the splints. 

The radius may be fractured through its head, generally in injuries in- 
volving the joint. Adjust it and apply an angular splint, supporting the 
elbow in a state of flexion. If the neck is fractured, the biceps will elevate 
the lower fragment ; the treatment is the same as for the former accident. All 
fractures above the attachment of the pronator quadratus must be so ad- 
justed that the proper axis of the bone is maintained to secure the restora- 
tion of its normal movements. The elbow should be semiflexed, the forearm 
and hand, excepting the fingers, supported between a dorsal and a palmar 
splint padded, and secured by adhesive plaster passed completely around the 
splints ; the limb should be accurately fixed in supination at an angle of 120° 
by means of angular pads ; the thumb in this position is brought nearly into 
a line with the outer fleshy border of the supinator radii longus. 

The epiphysis at the lower extremity of the radius is liable to be sepa- 
rated, giving the appearance of a Colles fracture. It is usually the result of 
a fall upon the palm of the hand, in which two forces 
act in an opposite direction — viz. the weight of the body 
and the resistance of the ground ; the bone yields near- 
est the point of impact, where the vibration is greatest 
and the bone is weakest — viz. the epiphyseal junction. 
The chief deformity is due to the projection of the lower 
end of the radial fragment upon the palmar surface, and 
of the carpal fragments upon the dorsal surface, which 
give the peculiar silver-fork appearance. 

The treatment should be the same as for fracture 
of one of the bones, but the splints should extend down 
to the middle of the hand. Small pads over the project- 
ing fragments aid in reducing the displacement. 

The femur is liable to forcible separation of its upper 
epiphysis only as the result of extreme violence. The 
slighter injuries which have heretofore been supposed to 
cause separation of the epiphysis have, it has been shown 
by Whitman, caused a partial fracture of the neck. The 
femur of the infant may be fractured at birth when an 
operation is performed, either by manipulation or with 
instruments. At other periods of infancy fracture of the femur is of rare 
occurrence, and is rarely met with except in severe accidents. These frac- 
tures are usually so nearly transverse that but little traction is required to 
retain the fragments in apposition. 

The treatment of fractures of the femur at birth must be limited to 
supporting the affected thigh by bandaging it to the other with a compress, 
as a napkin, placed between them. In infants under one year of age the 
same method is as useful as any that can be adopted. For children between 
one and five years of age Schede's method has been preferred by some, 
notably by Bryant of London. It is called " vertical extension." 




Position with limbs 
suspended (Bryant). 



It is as follows (Fig. 166) : A long, continuous band of plaster is fixed to both 



536 



LOCAL DISEASES. 



Fig. 16: 



sides of the injured limb as high as the seat of fracture, and applied so as to form 
a free loop below the sole. This long strip is then secured in the ordinary way by 
circular strips of plaster and by circular turns of a bandage. The leg, having been 
elevated, is then kept in a vertical position, with the corresponding side of the pelvis 
suspended by means of a piece of cord fixed to a loop of plaster, and either attached 
above to some object over the bed or slung over a pulley, with its free extremity sup- 
porting a weight. This does not necessitate constant and complete rest on the back. 
The extension is removed at the end of three weeks, and the limbs are allowed to 
rest on the bed. 

Hamilton remarks of the treatment of these fractures : ' : Fractures of 
the thigh in children have generally been found more difficult to manage 

than fractures of the same bone in the adult, 
owing chiefly to the shortness and softness of 
the limb, the delicacy of the skin, its liability 
to become excoriated or to become soiled, and 
the restlessness of the patient."' As a result 
of a large experience in the use of various ap- 
pliances in the fracture of the femur in older 
children lie devised the following, which is 
simple and very effectual : 

Two long side-splints connected by a cross-piece 
at the lower ends, and reaching upward to near the 
axillae, separated a little more widely below than 
above, so as to render the perineum more accessi- 
ble, are laid upon each side of the body. The four 
short thigh-splints, made of binder's board and 
covered with cotton cloth, are secured in place by 
four or five strips of bandage tied in front and then 
stitched to the covers of the splints. These must 
not embrace the long side-splint. The broken limb 
below the knee, and the opposite thigh and leg are 
held in place by bandages passed around the splint. 
Thus secured and laid upon a bed, such as I 
have already described as appropriate for children, 
the least possible annoyance will be given to the 
surgeon. The dressings are but little liable to be- 
J ]^^|iJ^j come wet with urine, and when the bed is soiled 

.g^ ~--f 1513^1 the child can be taken up with the splint and car- 

, : I ^_J' r 'i e< l t0 another: indeed, this may be done as often 

as the patient becomes restless or weary, without 
any risk of disturbing the fracture. In case the 
surgeon desires to use extension with adhesive plas- 
ter and weights, the necessary apparatus may be 
made fast to the bedstead and taken off when the 
child is moved ; or it may, if thought best, be made 
fast to the foot-piece of the splint. Occasionally, 
with children, I employ, as a means of extra safety, 
a perineal band drawn moderately tight, and fast- 
ened to the top of the splint on the side correspond- 
ing to the broken limb. The best perineal band is 
a piece of soft cotton cloth, one or two yards long 
by three inches wide, folded lengthwise to a flat 
band of one inch in breadth, and enclosing, where it passes through the perineum 
and under the nates, a few thicknesses of paper. The paper prevents its drawing 
into a round cord. Sometimes I place between the paper and the folded cloth, 
on the side which is to be laid next to the skin, one or two thicknesses of cotton 
wadding. To absorb the moisture it is well to lay a piece of sheet lint between the 
band and the skin. The perineal band may be removed daily and renewed, and the 
perineum examined and washed. Four or five weeks is generally a sufficient length 
of time for perfect consolidation in children under five years of age. 




Dressing for fracture of the femur 
in children, complete (Hamilton). 



INJUBIES OF BOXES. 537 

Separation of the lower epiphysis of the femur occurs from various 
applications of violence. It has resulted from traction on the legs at birth, 
from attempts to break up ankylosis at the knee, and while examining a case 
of hip-joint disease. The violence may be so great as to cause protrusion of 
the upper fragment through the skin. In several recorded instances the 
limb was caught in a wagon-wheel. No prescribed method of treatment can 
be given in complicated cases, but a double-inclined plane, with side-splints, 
in ordinary simple cases would best meet the indications. The following 
severe forms of this injury illustrate their peculiarities and dangers: 

Case 1. — Little presented to the New York Pathological Society a specimen 
obtained from his own practice. A boy, set. eleven, while hanging on the back of 
a wagon, had his right leg caught between the spokes of the wheel, which was in 
rapid motion. A few hours after the accident he found the upper fragment of the 
femur projecting through an opening in the upper and outer part of the popliteal 
space. On examination the wound did not appear to communicate with the knee- 
joint. Under the influence of an anaesthetic the fragments were reduced, the re- 
duction occasioning a dull cartilaginous crepitus. There was at the time no pulsa- 
tion in the posterior tibial artery, and the limb was cold. The limb was laid over 
a double-inclined plane. The following day the upper fragment was again dis- 
placed, and it was found that it could only be kept in place by extreme flexion of 
the leg. This position was therefore adopted and maintained ; considerable trau- 
matic fever followed, with swelling, and on the thirteenth day a secondary hemor- 
rhage occurred from the anterior tibial artery near its origin, and it became neces- 
sary to amputate. The boy made a good recovery. The specimen showed that the 
line of separation had not followed the cartilage throughout, but had at one point 
traversed the bony structure. 1 

Case 2. — Smallwood, a boy, aged twelve, had his right leg caught in the spokes 
of a wagon-wheel, breaking the thigh at the junction of the lower epiphysis with 
the diaphysis, the lower end of the upper fragment protruding five inches through 
the flesh. The end was nearly square. The lad being under the influence of 
ether, it was reduced within one hour by violent extension and flexion of the leg 
over his knee, one finger being in the wound and adjusting the fragments. Lateral 
splints were employed. The wound closed in about nine months, and in the mean- 
while two small fragments of bone escaped. He had also a sharp attack of syno- 
vitis. On recovery the leg was straight, but shortened three-quarters of an inch. 
There is complete ankylosis of the knee-joint, but the muscles of the leg are well 
developed and he walks with very little limp. 2 

Fracture of condyles in children is rare, and results only from direct vio- 
lence. The following case of fracture of the internal condyle is instructive : 

Case (Riggs, Homer, N. Y.).— A lad, eet. fifteen, was kicked by a horse, the blow 
being received upon the right knee. The internal condyle of the right femur was 
broken off, carrying away more than half the articulating surface of the joint : the 
tibia and fibula were at the same time dislocated inward and upward, carrying 
with thein the broken condyle and the patella. The displacement upward was 
about two inches, and the sharp point of the inner fragment had nearly penetrated 
the skin. There was no external wound. The knee presented a very extraordi- 
nary appearance, and the lad was suffering greatly. The first attempt at reduction 
was unsuccessful ; but in the second attempt, when the men aiding him were nearly 
exhausted in their efforts at extension and counter-extension, and while pressing 
forcibly with both hands upon the two condyles, the bones suddenly came into 
position, except that the breadth of the knee seemed to be slightly greater than the 
other — a circumstance which was probably due to the irregularities of the broken 
surfaces, which prevented perfect coaptation. Neither splints nor bandages were 
required to maintain the bones in place; the limb was placed upon u a double- 
inclined plane," which, being supplied with lateral supports, would prevent any 
deflection in either direction in case the limb was disposed to such displacement. 
The subsequent treatment consisted in the use of cold-water dressings. Very 

1 New York Journ. Med., 1865. 

2 Hamilton on Fractures and Dislocations, p. 427, 1891. 



538 LOCAL DISEASES. 

little inflammation followed. A portion of the integument sloughed, but the bone 
was not exposed, and it healed rapidly. On the twenty-fourth day passive motion 
was used, and this was repeated at intervals until, at the end of three months, he 
was able to walk with a cane. At the end of a year the knee was a very little 
larger than the other, and flexion was not quite as complete. In all other respects 
it was perfect, and the boy himself declared it was as good as the other. 1 

The tibia is less liable to fracture in children than the femur. Separa- 
tion of the upper epiphysis rarely occurs, and is to be treated by properly 
adjusted plaster-of-Paris dressings, unless the tissues are too much injured. 
Fractures in the shaft are rarely displaced, and require only adjustment. In 
infants employ a thin pasteboard splint moulded while wet to the leg poste- 
riorly and nearly meeting in front. It should be well protected by cotton 
batting. Separation of the lower epiphysis and fractures at the ankle are so 
rare as to require no further notice. 

The fibula is rarely fractured. Separation of the upper epiphysis has 
been recognized at autopsies, but has no practical importance. 

Fracture-sprains (Callender) at the ankle are now more frequently seen 
among boys engaged in athletic sports. The foot turns in or out, and either 
fractures a malleolus, generally the outer, or the lateral ligament drags off 
the end of the bone. These cases should receive applications of very hot 
water for twenty-four hours, and then the limb should be encased in a plas- 
ter-of-Paris dressing, well padded, for four weeks. 



CHAPTER IV. 

DISEASES OF BONE. 

Inflammation of the bones of children has some marked peculiarities. 
Owing to the prolonged process of ossification of the cartilage of the epiph- 
ysis of long bones, these highly vascular structures are peculiarly susceptible 
to traumatism, cold, and invasions of the pus-microbe and tubercle bacilli. 
The short bones, and especially the irregular bones of the carpus, tarsus, 
and vertebrae, are for the same reasons very susceptible to inflammation. 
The progress of these affections is also more rapid even in the chronic form, 
and the effects differ from the same diseases in the adult. In children 
superficial necrosis is much less frequent, as the supply of blood through 
the nutrient arteries is more abundant, thus supplying the bone when the 
periosteum is elevated, as by pus. Acute and chronic inflammations are 
more exhausting in childhood, and yet operative procedures are highly suc- 
cessful, both in the recovery of patients and in the reparative results. 

In the etiology of inflammatory affections of bone in children we have 
a striking peculiarity as compared with the adult in the frequency of infec- 
tion by the tubercle bacilli. 

This affection deserves the most careful study, for on its timely recognition 
will depend the success of the treatment. The tubercular inflammatory pro- 
cess is due to the lodgement of the pus-microbe, whether it follows an injury 
or is the result of a tubercular focus in other tissues. It may commence in 
the periosteum, the bone-tissue, or in the medulla : in either case all of the 
structures are liable to be involved in the final issue. Acute inflammation 
more often attacks the diaphyseal extremities of the long bones, owing to 

1 Hamilton : Fractures and Dislocations, 1891, p. 424. 



DISEASES OF BONE. 539 

the great vascularity of the epiphyseal connection, where the process of 
ossification of cartilage is actively in progress. On the walls of the imper- 
fectlv formed vessels the pus-microbe becomes implanted, and develops the 
active process of inflammation. At these points an acute endostitis, ostitis, 
or periostitis may commence and rapidly spread to the adjacent vascular 
structures. It is noticeable, however, that the layer of unossified cartilage 
acts as a barrier against the extension of the products of inflammation into 
the epiphyses, and hence in the direction of the joints. But the periosteum, 
by its connection with the cartilage, induces these products to spread rapidly 
along the loose subperiosteal areolar tissue, thus raising the periosteum from 
the bone. If the inflammation is less severe, the periosteum may become 
more firmly attached to the bone, and thus prevent the extension of purulent 
matters along the bone under the periosteum. Ulceration takes place, and 
the pus escapes externally at the epiphyseal junction. 

Acute inflammations of bones may be classified as follows : 1. Periostitis: 
«, subperiosteal ; b, supraperiosteal. 2. Osteomyelitis : a, epiphysitis ; b, di- 
aphysitis. 

Periostitis is a disease of youth, and rarely of infancy. It may be caused 
by injury, cold, or from the extension of osteomyelitis. When the disease is 
due to an injury, there is a lowering of the vitality of the tissue, which pre- 
pares it for the action of the pus-microbes in the circulation. The attack 
may follow the injury after several days, during which the microbes slowly 
find access to the blood-clot. 

When the periosteum alone is involved, as from traumatism, the inflam- 
mation will be located at the seat of injury, but if it is secondary to other 
inflammations, it will appear at the diaphyseal extremity of long bones. 
Acute periostitis often occurs during low forms of fever and during epidemics 
of the exanthemata. The lowered vitality of such patients renders them 
more susceptible to the action of germs. In the same manner we must ex- 
plain the occurrence of several cases in succession among persons living in 
close association. 

The symptoms of the two forms of periostitis differ only in intensity. In 
one the active inflammation is between the bone and deep fibrous layer of the 
periosteum, the pus forming the true subperiosteal abscess. The other occurs 
in the superficial areolar tissue of the periosteum. The former is liable to be 
followed by necrosis, while the latter does not affect the bone, but terminates 
in superficial abscess. The symptoms are alike, but are less severe in the 
latter case. 

In the subperiosteal form rigors, followed by a temperature of 103° to 
105° or 106° F., and subsequent delirium, are early indications of the severity 
of the attack. Drowsiness supervenes, and if the inflammation is subperios- 
teal the child utters piercing screams, owing to the distention of the perios- 
teum, though as yet it may give no indications of the source of pain, and 
there may be no local conditions directing attention to the seat of disease. At 
this stage the nature of the affection is very liable to be overlooked if the 
disease is subperiosteal, and the symptoms are often attributed to meningitis 
or other disease. If the inflammation is superficial, the general symptoms 
are not as severe, and the local swelling early determines the exact location 
of the trouble. In the subperiosteal variety, where there may at first be no 
swelling, there is one characteristic symptom present which must always be 
sought for in a suspicious case of this kind, and that is local tenderness on 
pressure. Whatever may be the condition of the patient's mind, he will in- 
stantly scream when pressure is made over the affected part. If the bone 
lies deeply, as the femur, prolonged search may be necessary to finally reach 
the exact locality, but by care it can always be found. 



540 LOCAL DISEASES. 

At a later period the periosteum is perforated, and diffuse cellulitis estab- 
lished ; the limb becomes swollen, often very largely, tense, and shining, and 
frequently the neighboring joint is involved. 

As a rule, the extension of the inflammation toward the joint is prevented 
by the attachment of the periosteum to the epiphyseal cartilage. At this 
point, however, it may extend more deeply, and detach the epiphysis from the 
shaft, and even establish an osteomyelitis. The extent of necrosis of the 
shaft depends upon the interruption of the circulation in the bone. It may 
be superficial when the periostitis is limited, or it may involve the entire 
thickness of the shaft, or the whole shaft may perish by the interruption of 
the circulation of all of the nutrient arteries, both external and internal. 

The diseases for which acute periostitis have been mistaken are fever, 
erysipelas, and rheumatism. Periostitis may be mistaken for fever when 
there is slight swelling and the most marked symptom is fever. 

Case (Macewen). — Child admitted to Glasgow Fever Hospital as a case of 
fever. She was quite insensible and in extremis. Examination of both legs showed 
scarcely a perceptible difference in size ; pressure on left tibia gave rise to the cha- 
racteristic scream ; no tenderness elsewhere. Autopsy showed the periosteum 
stripped from the whole tibial diaphysis by a pus which swarmed with staphylo- 
cocci. 

This case impresses the great importance of an examination of the long 
bones by pressure when the case is doubtful. 

Periostitis most resembles erysipelas when the inflammation involves only 
the superficial layer of periosteum. But there is never the defined and 
rapidly-spreading redness of erysipelas, while the severe and localized pain 
and dusky skin mark periosteitis. When the swelling involves the parts in 
the vicinity of a joint, the pain and swelling have a slight resemblance to 
rheumatism, but a careful examination of the parts readily shows that the 
joint-structures are not involved. 

Case. — A girl, aged seven, was seized with rigors, severe pain at the upper part 
of the leg: temperature 104° F. ; pulse 110; swelling just below the knee. Was 
treated as rheumatism for one week. Then periostitis was recognized ; an incision 
evacuated a large quantity of pus, with great relief; a superficial necrosis followed, 
and patient eventually recovered. 

The treatment should be prompt relief of the distended tissues by in- 
cisions down to the bone. These should never be more than two inches in 
length, and should be made in the long axis of the bone. It may be neces- 
sary to make such incisions in different parts of the limb, and care should be 
taken, when there is extensive suppuration, to make a sufficient number to 
completely evacuate the pus and to admit of thoroughly cleansing the cavity. 
If no pus appears, one or two incisions only may be necessary to relieve the 
tension ; but strict antiseptic measures must be taken to prevent the introduc- 
tion of pus-microbes. 

If there is suppuration, do not use force in exploring the wound, as by 
inserting the finger, that the periosteum may not be unnecessarily raised from 
the bone. The entire cavity and all of its recesses should be irrigated with 
carbolic solution (1:40), or bichloride (1:1000), or boric acid. Peroxide 
of hydrogen should be injected during the period of profuse suppuration. 
The limb should be squeezed as little as possible to force fluids out. It is 
well to make such incisions as will most effectually drain the wound by gravi- 
tation. Iodoform gauze next to the wound and antiseptic coverings complete 
the dressings. The dressing and cleansing of the wound should be repeated 
every two or three days, and as the discharge diminishes the interval may 



DISEASES OF BONE. 541 

be increased. At the first dressings strips of iodoform gauze may be pushed 
into the recesses of the abscesses. 

The subsidence of the severe symptoms on relieving the tension by incis- 
ion, and on evacuating a large cavity distended with pus, is usually very 
great, but the patient should be vigorously sustained by tonics, as quinine, 
iron, strychnine, cod-liver oil, etc. 

If the symptoms do not markedly improve, examine the limb carefully in 
order to detect any possible collection that has not been reached. In the 
upper part of the leg. where the disease seems to be chiefly on the anterior 
face of the tibia, pus sometimes accumulates on its posterior surface, and 
until that is reached the fever will continue. In some instances the inflam- 
mation has penetrated the medulla, and osteomyelitis results. The treatment 
must now be adapted to that disease, or symptoms of pyaemia may appear, 
with rigors, sweats, pallor, and rapid exhaustion. The cavity of the abscess 
should be explored to discover any cul-de-sac or concealed focus which, in 
spite of the irrigation, still retains decomposing pus. All such places must 
be rendered aseptic by vigorous cleansing and the tonic treatment pursued. 

Xecrosis is one of the results of periostitis always to be anticipated. It 
does not. however, necessarily occur even when the periosteum has been 
completely separated from the bone over a large surface. The shaft of the 
bone may continue to receive a sufficient supply of blood from the epiphyseal 
cartilages and the nutrient arteries to maintain its vitality until the perios- 
teum again becomes united. 

Case. — A girl, seven years old, suffered from extensive periostitis of the left 
thigh ; pus formed and burrowed extensively. On incision down to the bone a 
large amount of pus was discharged, and the bone was found to be completely 
exposed the entire length of the shaft. After a long period of suppuration the 
periosteum again became united and the child recovered without necrosis. 

When necrosis takes place the treatment of the dead bone must be very 
judicious. As a rule, no attempt to remove the sequestrum should be made 
until it has so far separated that it is movable. The period at which this 
will occur varies from one to many months, chiefly according to the extent 
of the necrosis. It is impossible to determine at an early period how exten- 
sive the necrosis will be, and if efforts are made to separate the apparently 
dead bone from the living, to which it is firmly attached, there is liable to be 
a destruction of nutrient vessels which will result in the death of bone that 
might have been saved. 

If the entire thickness of the shaft of a long bone becomes necrotic, no 
rude attempts should be made to separate the mass until it is movable, lest 
the involucrum be injured or broken. Free drainage should be maintained, 
and such cleansing of the dead structures by irrigation with antiseptic solu- 
tions as will prevent the retention of putrid pus. When there are evidences 
that the sequestrum is loose, the cavity should be opened in the direction of 
a sinus ; the cloacse in the involucrum must be sufficiently enlarged with a 
chisel or the gnawing forceps, and the mass seized with strong forceps. The 
first efforts to detach the dead bone from the living should be by gentle 
movements in its long axis; then more direct traction will dislodge it, but 
care must be taken not to fracture the bony investment. The after-treatment 
should be antiseptic. 

If the entire shaft dies, the case will assume a more serious aspect, but 
under judicious management a favorable result may generally be secured. 
The treatment should aim to prevent the collection of pus, to keep the cavity 
free from putrefactive materials, and support the general health. When the 
shaft has loosened or has become enclosed in new bone, the entire dead bone 
should be removed in the manner above described. 



542 LOCAL DISEASES. 

Chronic periostitis is characterized by a mild grade of symptoms as com- 
pared with those of the acute. It may be due to injury or au exanthematous 
fever, or to a specific cause, as syphilis or tuberculosis. If it follow an injuiy, 
there may be a thickening of the membrane simply, and then of the bone, or 
pus may form, with a more or less extensive abscess. When it appears as a 
sequela of an eruptive fever, it resembles the periosteitis sometimes seen dur- 
ing pyaemia, and is probably really due to the lodgement of some septic mat- 
ters transmitted through the circulation from the local eruption. The sub- 
jects of this form are feeble and poorly nourished, and the suppuration is 
often extensive, without any marked symptoms. 

In the tubercular form the child usually has the signs of a strumous diath- 
esis. The progress of the case may be very slow, but occasionally it is more 
acute ; in any case it tends to the formation of purulent collections. It may 
subside on the evacuation of the pus or inflammation may extend to the 
medulla. 

Syphilitic periostitis may be due to the congenital or acquired form of 
syphilis. When congenital it more often appears after the fourth year, and 
is generally found in several bones, especially of the upper limbs and the 
tibia. It is often symmetrical in its attacks, nodes appearing at the same 
point of the same bones of the opposite limbs. 

The treatment consists in sustaining the general health, the evacuation 
of collections of pus, and cleansing cavities by curetting and disinfection, and 
the removal of dead bone. If the disease is of a syphilitic origin, antisyph- 
ilitic remedies must be employed. 

Acute epiphysitis (circumscribed osteomyelitis) is more frequent in chil- 
dren than the diffuse variety, and is localized at the epiphyseal junction of 
long bones. It more often occurs at the lower end of the femur. It com- 
mences in the succulent tissues connected with the ossifying process of the 
epiphyseal cartilage, and involves the cancellous tissue of the epiphysis. It 
progresses toward suppuration, and a cavity forms containing pus, giving rise 
to an abscess of bone. The pus may from this point pass into the neighbor- 
ing joint or along the shaft or to the medulla, where the inflammation spreads 
as a diffuse osteomyelitis. The epiphysis may become detached. 

The causes of epiphysitis are injury, exposure to cold, an exanthem, or 
infection from an existing suppurative focus. The new-formed vessels in the 
ossifying cartilage are susceptible of such changes by injury, cold, and other 
conditions that leucocytes adhere to their walls. If any infective materials 
are floating in the circulation, it is more liable to find lodgement in these 
vessels than in any other. 

The symptoms are usually very pronounced. Fever, pain, and exhaus- 
tion follow rapidly. The pain, which is the most marked early symptom, is 
of a gnawing, boring character, while the pus is confined by dense structures, 
and relief comes only when the pus passes out into yielding tissues, as through 
the periosteum or into the joint. The position of the limb is semi-flexed, 
which in some degree relieves tension. Exhaustion necessarily follows as a 
result of the fever, pain, and disturbance of nutrition. 

The conditions of greatest importance in diagnosis are as follows : In 
the early stage, when there may be no swelling of the part nor of the joint, 
by careful manipulation a marked tenderness will be found at the seat of 
disease. This point of acute tenderness is very characteristic. When the 
parts are swollen by the approach of the pus to the surface and the joint is 
involved, attention must be chiefly given to the early history in order to 
exclude rheumatism and periostitis. 

Case. — A boy, age ten years, had continued gnawing pain below knee, moderate 
fever, loss of sleep except under the influence of opiates ; knee not swollen, but 



DISEASES OF BONE. 543 

flexed. Symptoms had existed more than a month, but had become more severe 
within a few days. He was suffering acutely on admission from pain in left knee ; 
temperature 102° F. There was considerable swelling about the inside of the upper 
end of the tibia, where there was marked tenderness. An incision at this point 
down to the bone showed evidences of inflammation, but no pus. A small trephine 
was applied to the bone, which exposed the cancellated tissue infiltrated with pus, 
and very soft, but no distinct cavity. The wound was treated antiseptically, but 
subsequently the knee became involved and required to be opened, and carious 
bone was removed from the head of the tibia. Persistent use of antiseptic meas- 
ures locally and tonic treatment restored the patient to health with a useful limb. 

The treatment is the evacuation of the pus by freely opening the soft 
parts ; if pus is not found, the bone should be penetrated and the abscess 
fully exposed. The cavity should be freed of any necrotic bone-tissue, 
cleansed, and completely disinfected. If the joint is involved in the sup- 
puration, it must be sufficiently exposed to remove all the pus and be disin- 
fected and drained. In cases which have set up osteomyelitis the shaft of 
the bone should be trephined at such points as will evacuate the pus, and fre- 
quent cleansing and disinfection should be practised to preyent septicaemia 
and pyaemia. In extreme cases amputation may be necessary to save the life 
of the patient. 

Such authorities as Fayrer and Macnamara, according to Owen, are strong in 
urging amputation and reamputation, and the less the delay in resorting to the ope- 
ration the better. " After rigors (convulsions) and other symptoms, including 
pyaemia, have commenced, by far the best prospect is to remove the whole bone." 

Growing fever has been described as occurring in children of from seven 
to fifteen years. The pain is located at the epiphyseal lines ; there is rapid 
growth and some fever at times, with general disturbance. The symptoms 
usually subside without unfavorable results, but osteomyelitis may occur and 
exostoses may form. 1 

Acute osteomyelitis, or diaphysitis, is a suppurative inflammation of the 
marrow of bone. It is a very common and destructive disease of childhood. 
It has its origin in the infection of the medullary structure of bone by pus- 
microbes. Though all bones are liable to be affected, the disease more often 
appears in the shafts of the long bones, and especially in the vicinity of the 
epiphyseal extremities. This is due to the fact that at these points the active 
process of ossification of the epiphyseal cartilage is in progress, and the newly 
and as yet imperfectly formed vessels readily admit the implantation of the 
microbes, floating in the blood, on their walls. The inflammation begins 
within these vessels, and spreads with the leucocytes into the medullary 
tissue. The large veins become occluded with thrombi which become infected 
by pus-microbes, followed by liquefaction of the coagulated blood. From this 
condition may result abscesses, or necrosis from the interruption of the cir- 
culation, or pyaemia from the entrance of infective matters into the general 
circulation. The infection gradually extends to the periosteum, and suppura- 
tive periostitis ensues, with separation of the periosteum from the bone ; or 
the periosteum may yield and pus enter the cellular tissue, causing wide- 
spread cellulitis. 

The origin of the pus-microbes which cause osteomyelitis is often a sup- 
purating wound, but they may enter the circulation through the lungs or the 
intestinal canal. A recent injury, as a fracture, may furnish all the con- 
ditions necessary for the lodgement of microbes entering the circulation from 
an existing wound. The infectious diseases of childhood, as scarlet fever, 
measles, diphtheria, and typhoid fever, often furnish the microbes which in- 
duce inflammation of the medulla. These cases are not generally pyaemic. 
for the patients usually die of exhaustion. 

1 Brit. Med. Journ., April 14, 1888, p. 320. 



544 LOCAL DISEASES. 

Case (Owen). — An infant, aged four weeks, was admitted to hospital on Feb- 
ruary 7th. An acute abscess involved the lower third of the left thigh, and another 
was present above the ankle of the same limb. There were also two small subcuta- 
neous abscesses in the palm and little finger of the left hand. These abscesses de- 
veloped a few days later, suppuration occurring in cutaneous sores on the arm. The 
abscesses were opened, flushed, and drained, but the child died two days afterward. 
The post-mortem examination showed that the abscess above the knee led to bare 
bone at the diaphyseal surface of the lower epiphyseal cartilage of the femur, and 
the end of the diaphysis was in a condition of acute osteomyelitis. There was no 
actual cavity in the bone, and the knee-joint was not involved. The abscess above 
the ankle led to bare bone at the tibial diaphysis, which was partially necrosed and 
surrounded by a good deal of new bone. The ankle-joint was not involved. There 
was a similar condition of the sternal ends of the third right and fourth left ribs 
and of the spinal ends of the seventh and eighth ribs, in each case the end of the 
rib being necrosed. There was also in this case purulent meningitis affecting the 
convexity of the brain, but no other sign of pygemia was present. 1 

The frequent occurrence of this disease after exposure to the effects of 
cold, as prolonged bathing or lying on the ground after vigorous exercise, is 
explained by Senn as probably due to the congestion which takes place at 
these nutritive points, where resistance is least, and then the mural implanta- 
tion of microbes circulating in the blood. The disease may progress with 
great rapidity, with more or less violent symptoms, or it may proceed slowly 
and assume a chronic form. 

Diapliysitis, or osteomyelitis of the shaft of the bone, in its acute form 
is ushered in by a chill, followed by fever ; severe pain, but not well local- 
ized ; tenderness at the point of most acute inflammatory action ; swelling is 
a later sign, attended by a dusky redness of the skin as the pus approaches 
the surface ; swelling of the neighboring joint and synovitis complicate the 
case at an early period. As swelling may be a late symptom, the fever may 
be mistaken for typhoid fever. The swelling of the joint often leads to the 
diagnosis of rheumatism. In later stages it may be taken for cellulitis, 
periostitis, or ostitis. There is no one characteristic symptom. 

Case (Goltdammer). — Patient had been suffering ten days with fever ; pulse 110 
to 120 •, tympanites ; dry tongue ; bronchitis ; delirium ; was diagnosed as typhoid 
fever. On close examination a slight swelling with tenderness was found over 
lower part of tibia, which proved to be osteomyelitis. 

The diagnosis must be made on this line of inquiry. The chill and 
fever are soon followed by pain, which is deep-seated, boring, tearing, and 
throbbing in the affected limb. In a brief period a careful examination 
reveals at the epiphyseal junction a tenderness, well localized, which is the 
focus of the inflammation ; this tenderness becomes more and more marked, 
until a swelling appears which indicates the approach of pus to the surface. 

The treatment should be prompt and decisive when the diagnosis is 
satisfactorily made out. It must be borne in mind that the focus of inflam- 
mation is in the interior of the bone, and that the active cause is the pus- 
microbe. Until that is removed the suppurating process will continue its 
destructive work. It becomes the imperative duty of the surgeon to expose 
this focus, to thoroughly disinfect the cavity, and, as far as possible, the 
adjacent structures. When this operation is rightly performed, the change 
in all of the conditions is very great ; the pain subsides, the swelling dimin- 
ishes, the fever falls, and the patient secures sleep and much-needed rest. 
But the great value of this treatment is the arrest of a destructive inflamma- 
tion which was liable to terminate in pyaemia, necrosis, suppuration in the 
nearest joint, and possibly in loss of limb and even of life. 

1 Lancet, May 5, 1894. 



DISEASES OF BONE. 545 

Case (Pitts). — An infant, aged six weeks, was admitted to hospital on Jan. 5th. 
In this ease the disease followed a few days after inflammation and suppuration in 
some cutaneous sores. There was an acute abscess above the left clavicle, and 
another above the left knee. On opening the former abscess the entire diaphysis of 
the clavicle came away as a sequestrum, which lay loose in the abscess-cavity. The 
femoral abscess led to a cavity in the region of the epiphyseal cartilage, which con- 
tained a small sequestrum. The knee-joint and shoulder-joint were not involved. 
The child died five days afterward. The necropsy revealed necrosis of the acromial 
end of the right clavicle, suppuration in the acromio-clavicular joint, and necrosis 
of the sternal end of the fourth rib on the right side and of the spinal end of the 
eighth rib on the same side. Subpleural abscesses were found in each case. 1 

There may be no guide to the seat of the disease but tenderness on 
pressure. At that point, or as near it as the vessels and nerves will admit, 
an incision should be made down to the muscles ; these should be separated 
and the periosteum exposed. Usually the deeper tissues give marked evi- 
dence of inflammation, but even that condition may not exist, and on 
exposing the periosteum there may be no appearance of disease other than 
congestion. This fact should not deter the operator from proceeding to open 
the bone. A small trephine may be used, but a semicircular chisel is to be 
preferred. The opening is to be in the direction of the centre of the bone. 
When the medulla is reached, if pus has not formed, the tissues will be con- 
gested and soft, and blood and serum will be discharged. If an abscess 
exists, there will be a free flow of pus. 

As the object of exposing the cavity is to remove all of the diseased 
tissue, it may be necessary to enlarge the opening, which should be in the 
direction of the axis of the bone. If the inflammation involves a large ex- 
tent of bone, it is better to make several openings rather than a single one. 
When the cavity is sufficiently exposed, all of the diseased tissue should be 
removed with a sharp spoon ; the cavity should be irrigated with a sublimate 
solution (1 : 5000) ; peroxide of hydrogen or a solution of chloride of zinc 
(10 per cent.) should be applied to all the surfaces ; the cavity should then 
be packed with strips of iodoform gauze and the parts covered with anti- 
septic dressings. The limb should be fixed in a comfortable position, which 
favors the circulation. The dressings should be repeated, and the cavity 
cleansed by irrigations with warm boracic- or carbolic-acid solutions or perox- 
ide of hydrogen. If the temperature indicates an extension of the sup- 
purating process, the parts involved must be exposed and treated as indi- 
cated. If the operation is delayed until the suppuration is extensive, 
incisions should be made at such points as will freely evacuate the pus rather 
than by one long incision. The treatment should then be conducted on the 
lines already given. 

Necrosis is one of the later complications of the severer forms of osteo- 
myelitis. The most important feature in the treatment is to maintain, as far 
as possible, an aseptic condition of the entire cavity, and not to attempt 
removal of the dead bone until it has become so far detached that it can be 
removed without damage to the living bone. Frequent trials with a probe 
may be made through the openings to the dead bone to determine whether it 
is loose. If the involucrum is large, the granulations may so enclose the 
dead mass as to make it quite difficult to detect actual separations without 
force. When the sequestrum moves' in its place on pressure with the probe, 
it will probably be found necessary to enlarge the opening in the bone 
(cloacae) to make it possible to withdraw it from the involucrum. If this 
enlarged opening does not give sufficient space, the bridge between two or 
more cloacae may be removed with rongeur forceps or chisel, always in the 
direction of the shaft. 

1 Lancet, May 5, 1894. 
35 



546 LOCAL DISEASES. 

Necrosis of the entire diapliysis sometimes occurs by the extension of 
the destructive process. The management of these cases is beset with 
difficulties. The conditions may be such, when the patient is first seen, as to 
raise the question of immediate removal of the necrosed bone or even of 
amputation. If the sequestrum is loose and the patient is failing, removal 
may be at once effected, though the new bone is imperfect. If it is not 
loose, the effort must first be made to secure complete evacuation of the pus 
and cleansing and disinfection of the cavity. Usually improvement follows, 
and an operation may be delayed. Failing to secure a better condition, 
sequestrotomy or amputation may be necessary as an extreme measure. The 
former operation is to be selected if there is an even chance of recovery, the 
latter being a last resort. 

In general, two features in the treatment are of great importance — viz. : 
1. If possible, the dead bone should not be removed until the involucrum is 
sufficiently formed to sustain the limb ; 2. The epiphysis should be preserved 
in order to prevent subsequent shortening. 

The chief danger to be apprehended in these cases is the exhaustion of 
the patient by septicaemia, owing to the necessary presence of a large amount 
of septic matter. 

Case (Masterman). 1 — A girl, aged eleven years, had a rigor with high fever, 
nausea, headache ; no history of injury ; no complaint of pain in the limbs. Diag- 
nosis was an ordinary case of rigor. On the second day there was fever, vomiting, 
and redness along the right leg. Diagnosis was commencing erysipelas. Eight days 
after the temperature was 103° F. ; joints stiff and painful, especially the wrists and 
elbows ; right leg was swollen, but redness was gone : there was fluctuation over 
the inner surface of the tibia, extending four inches up the leg from the malleolus ; 
the skin was white, but not tense. On incision pus escaped, and the tibia was found 
bare over a surface of two inches. Symptoms became worse, being marked by rigors 
and sweats ; the joints became more swollen and painful, and pyaemia terminated 
the life of the child on the seventeenth day from the attack. 

To guard against this danger, as free exit of pus must be secured as pos- 
sible, and thorough antiseptic irrigation of the entire necrosed surfaces and 
the cavity in which the dead bone is encased. At the same time, the patient 
must be surrounded with the best hygienic conditions, and be sustained by 
proper food and tonic remedies. Should chills and perspirations indicate a 
pyaemic state, the chief reliance must be on large doses of quinine and alco- 
holic stimulants. The amount and kind of stimulants which are given must 
be determined by the conditions in each case, as age, severity of the symp- 
toms, and susceptibility of patient ; but it must be remembered that children 
suffering from this affection are remarkably tolerant of alcoholic stimulants. 
Should the case progress favorably, the new bone will form under the raised 
periosteum, and gradually become so thick and firm as to be capable of sus- 
taining the limb. At this time the necrosed shaft is usually found to have 
separated from the epiphyses sufficiently to be removed without damage to 
the involucrum. The exact time of separation can scarcely be approximately 
fixed. In general, it may be stated that small bones, as the phalanges, may 
separate in four or five weeks ; superficial masses of the long bones may 
separate in seven or eight weeks ; while the entire shaft may require three 
to six, or even eight, months. 

The question of operation must depend largely upon the fact that the 
sequestrum is loose. The date should be fixed according to the condition of 
the patient. If the health is improving, there is no haste. But, having de- 
cided to remove the dead mass, all necessary antiseptic precautions should be 

1 Lancet, March 30, 1895, p. 804. 



DISEASES OF BONE. 547 

taken. The elastic bandage should be applied at some distance- above the 
point of incision after the limb has been elevated for a few minutes. 

The elastic bandage should not be applied from the toes or fingers, as it 
miaht force pus beyond the diseased area. Senn advises applying the band- 
age at a point above, where the muscles are large, in order to protect the 
nerves from undue pressure, as he has known it to cause temporary paralysis. 

The incision should be in one of the fistulous openings, unless important 
vessels or nerves are likely to be involved, and should be in the direction 
of the fibres of the muscles. In following this rule great care should be 
taken to avoid injury to nerves and arteries which may be in close proximity 
to sinuses, as the radials in the arm and the popliteal vessels and nerves. 
When the incision reaches the muscles, it is better to separate parts with the 
handle of the scalpel down to the bone. 

When the bone is exposed great care must be exercised in enlarging the 
opening in the involucrum. The chisel should be carefully employed to en- 
large the opening in the direction of the long axis of the shaft, the limb 
meantime being placed on a firm surface, so as to avoid the possibility of 
breaking the new bone, which is very hard and brittle. When the cavity in 
which the sequestrum lies is fully exposed, the shaft should be gently de- 
tached from the healthy bone at each end, and from the granulations which 
enclose it. and then lifted out of its bed. The cavity should be thoroughly 
curetted to remove all granulations, washed with a sublimate solution (1 : 5000), 
and dried with an antiseptic sponge. 

The healing of these wounds is greatly retarded by their unyielding walls, 
and hence many efforts have been made to facilitate the process. The most 
simple is that of Schede, who closed the soft parts with sutures, and allowed 
the cavity to fill with blood ; the blood-clot organized, and thus the process 
of healing was greatly promoted. Careful antiseptic methods were employed 
in dressing the wounds. Senn fills the cavity with decalcified bone-chips and 
sutures the periosteum and soft parts over the cavity. 

Senn states that the decalcified bone-chips are preserved in an alcoholic solution 
of corrosive sublimate (1 : 500) or a solution of iodoform in sulphuric ether. The 
implantation is made before the removal of the constrictor, in order that after this 
is done sufficient blood will escape to fill the spaces between the chips, and thus 
serve the useful purpose of a temporary cement-substance. After the surface has 
been dusted over lightly with iodoform the chips, which have been washed previ- 
ously in an antiseptic solution, are dried upon a gauze compress, and are then poured 
into the cavity until this is packed with them as far as the periosteum. The peri- 
osteum is then sutured over the surface of the bone-chips. 

Chronic circumscribed osteomyelitis differs from the acute form in the 
comparative mildness of the symptoms and its slow progress. It may con- 
tinue for a long period with no more marked symptom than an aching pain at 
night, and even this may not be noticed in young children. On this account 
it is a disease which is very liable to be long overlooked in cases where it is 
marked by great chronicity. 

In the progress of the disease there is usually much condensation of the 
bone surrounding the abscess. In very young children, however, the pus may 
come to the surface with very little disturbance, or it may extend as in diffuse 
osteomyelitis. Occasionally neglected cases are seen where feeble children 
have many sinuses leading to dead bone. 

Case. — A girl, aged ten years, received a blow on the left knee, from which she 
seemed to recover ; two or three weeks after the knee and the lower part of the 
femur began to swell ; the pain was not severe, and the fever was slight. At length 
fluctuation was detected, and on opening the abscess above the knee and at the inner 
side of the femur, a large amount of pus was discharged. The bone was enlarged. 



548 LOCAL DISEASES. 

and the probe entered a small sinus leading to the centre of the shaft. This was 
enlarged, and a cavity was found, involving the epiphysis, and containing a small 
sequestrum. A similar abscess of the upper extremity of the left humerus formed 
soon after, and on opening it carious bone was removed. She made a good recovery. 

The treatment which most immediately effects relief is incision, expos- 
ure of the bone, and trephining. The true guide to the focus of disease is 
tenderness. If great care is taken to make out this point, it is very certain 
to indicate the precise place for the incision. There should be no hesitation 
in exposing the bone by incision and in opening the bone by trephine or chisel, 
for the failure to find pus by no means renders the operation useless. Not 
infrequently the cancellous tissue is simply very red, with, perhaps, a serous 
infiltration and a few drops of pus. But the relief is uniformly great, as the 
tension is removed, and the inflammatory process is much relieved and modi- 
fied. In many instances an early operation prevents the pus from finding its 
way into a joint. The disease does not always become located in the epiph- 
ysis, but occasionally appears in the shaft, when the operation must be 
made in that region, the precise point being where the tip of the finger elicits 
evidence of the most tenderness. The cavity should always be thoroughly 
scraped, disinfected, and drained, and antiseptic dressings employed. 

Chronic diffuse osteomyelitis occurs most often in poorly-nourished and 
scrofulous children, and is caused by injuries, colds, and infective matters 
from suppurating foci. The exact point of commencement is not always 
apparent, but the first evidences of trouble appear usually at the epiphysis. 
unless the disease results from periostitis. It may. however, be met with in 
the jaw, ribs, pelvis, and other bones when there is a tubercular condition. 

The symptoms are frequently very obscure and the actual evidence of 
disease of the bone is limited to pain in the part at irregular intervals. But 
at length swelling of the tissues at the seat of pain, and, finally, the escape of 
pus and the formation of sinuses leading to bone, prove the existence of dif- 
fuse osteomyelitis. The destruction of bone may be very great, involving- 
sometimes the separation of an epiphysis or necrosis of the shaft, or even of 
both. The joints may become involved, with the formation of pus. 

The progress of the case is very slow, and the sequestra are frequently 
surrounded with soft and imperfectly-formed new bone. Attempts to remove 
sequestra by opening the new bone may result in breaking it up. when there 
is likely to be a tedious effort at repair. Even when the new bone appears 
to be firm the disease extends in spite of operations for the evacuation of 
pus, the cleaning out of sinuses and abscesses, and the removal of sequestra. 

Case. — A boy. aged five years, fell, striking on the left elbow. The bruise, was 
soon recovered from, but in a month following there were pain and swelling of the 
injured elbow, extending to the upper part of the arm. It was tense, and fluctua- 
tion was detected above the joint on the inner side : a puncture evacuated a 
quantity of pus. The bone was uncovered for a distance of three inches. The 
child was in feeble condition, but still able to run about and play. The arm seemed 
to improve for a time, but subsequently the elbow-joint became involved : pus was 
discharged through an incision, but there was no destruction of cartilage. After a 
period of apparent recovery the arm again became swollen, with pain and fever. 
Deep-seated fluctuation was detected, and on incision a large amount of pus 
escaped. The shaft of the bone was uncovered, the periosteum was greatly thick- 
ened, and there were evidences of the formation of new bone. After a period of 
four months the central portion of the shaft separated and was removed. The child 
recovered, with a much enlarged humerus. 

This form of osteomyelitis may result in sclerosis of the bone, with ob- 
literation of much of the medulla and general enlargement of the shaft. At 
points along the shaft there may be necrosis of small masses, enclosed by 



DISEASES OF BONE. 549 

the new bone. Again, the inflammation may be a rarefying process, the bone 
becoming enlarged, soft, and filled with granulations. With careful treat- 
ment the patient may recover and regain a useful limb. In a large number 
of the>e oases the tubercular condition is recognized. 

The treatment of this disease should always be very conservative, for 
recoveries take place under the most unfavorable conditions. It must always 
be borne in mind that these patients are probably tuberculous, and are cer- 
tainly feebly constituted. Every necessary means should, therefore, be 
employed to improve the general health. The local treatment is to be con- 
ducted on the same principles as that already given. If there are signs of 
the formation of pus. incisions must be made, and, if necessary, the bone 
must be opened and all cavities scraped and disinfected. All necrotic tis- 
sues must be removed, however extensive may be the operation. In tuber- 
culous cases the exposed cavities must be thoroughly curetted. 

Tuberculosis of Bone. — Children recognized as scrofulous or strumous are 
very liable to develop tuberculosis of bone. It has been known in its various 
forms as abscess, osteomyelitis, spina ventosa, hip disease, spinal caries, etc. 
The disease results from the escape of the tubercle bacilli from lymphatic 
glands or the lungs, where they have already formed foci, into the general 
circulation, and their lodgement in the tissues of the bone. It is not. there- 
fore, a primary disease in the individual, but is due to the emigration of 
the microbe, already fixed in other and more favored situations, to the osseous 
structures. The process of infection is as follows : The bacillus of this 
affected tissue enters the circulation, and is arrested in a minute artery, where 
it becomes attached to the wall ; a thrombus now forms around it, which 
finally completely obstructs the vessel ; a focus of infection is thus created 
and a pathological process commenced. This results in decalcification 
or osteoporosis, while the disease continues. It may terminate by progres- 
sive invasion of healthy tissues, or osteosclerosis of the surrounding bone 
may occur as the process subsides, and thus the focus will be effectually en- 
closed. 

The localization of the tubercle bacilli is at the centre of active growth, 
and hence they are found in the medullary tissue of the cancellated struc- 
tures in the vicinity of the epiphyseal cartilages. The newly-formed vessels 
are imperfect and irregular, and furnish conditions favorable for intercepting 
any particle floating in the current of blood. Tubercle is therefore most 
often found in the vertebrae, the carpal and tarsal bones, and the epiphyseal 
extremities of the long bones. It is rare that there is a single focus ; fre- 
quently two or more appear in the same part, and occasionally the opposite 
limb becomes involved. 

The granulation process set up in the infected part is not unlike that in 
the glands, and may terminate in caseation and subsequent liquefaction, or 
suppuration owing to the presence of pathogenic germs. Konig recognizes 
four principal groups: 1. The granulating focus; 2. The tubercular necro- 
sis ; 3. The tuberculous infarct ; 4. Diffuse tuberculous osteomyelitis. 

1. The granulating focus exists as a small cavity the size of a pea or a 
hazelnut, and may contain living embryonal tissues, or this may have been 
destroyed by necrosis and caseation, and the cavity contain cheesy material or 
tuberculous pus. 

2. If the infected area is of considerable size or larger than a hazelnut, 
the vessels surrounding it become obstructed and necrosis of bone results. 
In this case a sequestrum will be found in the cavity, the size, color, and 
porosity of which will depend upon the rapidity of the inflammatory changes. 

3. The tuberculous infarct is a wedge-shaped sequestrum, due to the 
formation of an embolism containing tubercle bacilli in a branch of the 



550 LOCAL DISEASES. 

nutrient artery. The base of this necrosed bone may involve a joint, and 
may escape detection. 

4. The diffuse form of tuberculous osteomyelitis is a rapidly-spreading 
inflammation of bone characterized by the presence of the tubercle bacilli. 
It closely resembles acute suppurative osteomyelitis, and is liable to prove 
fatal by the exhaustion which it produces. 

The diagnosis of tuberculosis of bone is frequently very difficult, as the 
general symptoms often do not indicate the extent, or even the presence, of 
the disease. An apparent condition of health is not incompatible with ex- 
tensive osteo-tuberculosis. But Senn states that " in 95 out of every 100 cases 
chronic inflammation in bone means tuberculosis." The earliest symptom 
which may readily be recognized is a daily rise of evening temperature, 
even if not more than half a degree, continuing for weeks. Careful search 
should be made, in a suspicious case having this symptom, for tubercular dis- 
ease of bone. A second important symptom is progressive angemia. Pain, 
though a constant symptom, is very variable in intensity, depending chiefly 
upon the severity of the inflammation. Its value must be estimated in each 
individual case. Tenderness at the point of infection is always present, and 
when carefully tested is reliable in localizing the focus of disease. Swelling 
does not appear until the pressure of the contents of the cavity begins to 
affect the external wall, as in spina ventosa, or in the progress of the disease 
the walls have been perforated, when a soft semi-fluctuating swelling is 
found. A dusky redness of the skin now marks the focus of disease, and at 
length the skin yields to the pressure, an irregular opening forms, and the 
contents of the abscess escape. The limb undergoes marked atrophy as the 
disease progresses. 

The differential diagnosis depends upon the discovery of the tubercle 
bacilli. The focus can be explored, for the purpose of extracting its con- 
tents, with a needle or with a hypodermic syringe, as the bone is quite soft. 
The needle should be inserted with a rotary motion. It will also determine 
the density of bone and the size of the abscess-cavity, besides withdrawing 
its contents. 

The prognosis depends upon the location of the infected part, the prog- 
ress of the disease, and the condition of the patient. In general, the prog- 
nosis is good when the focus of disease is accessible, the progress slow, and 
the patient is in fair health. It may be possible to remove the infectious 
material, and by a change of climate restore the general health of the 
patient. If, however, the diseased focus is inaccessible, the prognosis is 
more doubtful, and the danger is increased if pus-microbes gain access to the 
abscess. It must be remembered that a child who has once suffered from 
tuberculosis of bone is liable to future attacks. 

The treatment is general and local. It'is of the first importance to im- 
prove the health of the child by suitable medicines, as iron, quinine, phos- 
phorus, arsenic, strychnine, and cod-liver oil, and hygienic measures, as pure 
air, nutritious food, and bathing. Removal of the patient to the mountains 
or seashore at proper seasons of the year has a most marked influence on the 
progress of the disease, especially if the child is a resident of the city. The 
local treatment depends upon the stage of the disease and the accessibility 
of the part affected. 

The local treatment should first consist in the removal of all sources of 
irritation and in securing complete rest of the tissues involved. The immo- 
bilization of a limb, its elevation and rest, and the removal of pressure, are 
the immediate measures requiring attention. Destruction of the tuber- 
cular infection at the focus of disease should be attempted as early as possi- 
ble. In this procedure every necessary antiseptic precaution should be taken 



DISEASES OF BONE. 551 

to prevent the entrance of pus-microbes into the cavity, for the violent in- 
flammation which they excite has hitherto proved a most dangerous incident 
in the progress of the case. Two methods are recommended : Ignipuncture 1 
consists in the insertion of the needle-point of a Paquelin cautery heated to 
a dull-red heat. It should penetrate slowly, being frequently withdrawn and 
heated again. When it enters the cavity, the resistance suddenly diminishes. 
The results obtained are — free drainage of the cavity, the destruction of 
some portion of its contents, and the excitement of a plastic inflammation 
which tends to limit the infection. Through the track of the needle iodo- 
form solutions may be applied to the focus of disease. This treatment is 
adapted to foci in the epiphyses of long bones and in the carpus and tarsus. 
Pain is usually relieved and a healthy process of cicatrization established. 
But the removal of the tuberculous collection by incision is the most effective 
method of relief. This consists in exposing the cavity by dissection, perfora- 
tion of the bone by chisel or trephine, removing the contents, and curetting 
the walls. This operation is most successful when performed early and 
before caseation has occurred. The limb should be rendered bloodless by the 
elastic bandage, that the cavity may be thoroughly examined. Care should 
be taken to discover every possible collection of tubercle, explorations being 
made for any foci adjacent by means of a perforator, and the search should 
not cease until healthy bone is reached. In some instances it may be well to 
use the point of the cautery in doubtful places to destroy any infective 
material and excite healthy reparative action. 

The dressing consists in thoroughly cleansing the cavity with an anti- 
septic solution and packing it with iodoform gauze. Senn 2 advises to pack 
the cavity with decalcified bone-chips and to suture the periosteum over it, 
draining with a few threads of catgut. This treatment he regards as import- 
ant in the prevention of a local recurrence and general infection. 

He states that "if all the infected tissues have been removed, and no infection 
with pas-microbes has taken place during or after the operation, the wound unites 
under one dressing in from one to two weeks, and the definitive healing of the 
cavity is completed in the course of three to six weeks, according to the condition 
and age of the patient and the size of the cavity." Should suppuration follow, a 
secondary implantation can be made, when the cavity is made thoroughly aseptic. 

It sometimes becomes necessary to remove portions of the shaft of long 
bones, and when the carpus and tarsus are involved entire bones may require 
extirpation. In extensive osteomyelitis amputation may be the only suc- 
cessful method of saving the patient. 

Acute suppurative arthritis 3 is now re-cognized as a not infrequent disease 
of very early infancy. It has its origin generally in the epiphyses of the 
long bones and penetrates rapidly into the joint, destroying the cancellated 
structure of the bone, and perforating the joint surface. It may follow an 
injury or an exanthem, but the exciting cause is often unknown. Wright 
has seen a case which gave some evidence that the onset of the disease oc- 
curred in utero. The age of the child is quite characteristic. Though the 
disease may appear in older children, by far the larger number affected are 
under two years of age. The joint swells rapidly, and this swelling may 
involve the entire limb ; other joints sometimes swell, and for a time it may 
be impossible to determine the final location of the disease ; one joint, how- 
ever, soon becomes chiefly involved and the swelling subsides in the other 
joints. The hip is, perhaps, more frequently affected than the knee, but it is 
more often distinctly recognized in the latter joint. 

1 Richet. 2 Principles of Surgery. 

3 T. Smith, Brit. Med. Journ., Jan., 1885. 



552 LOCAL DISEASES. 

The treatment consists in the prompt evacuation of the pus by incision 
and drainage. The first operation should be searching, and such incisions 
should be made as will not only drain the abscess at the time, but will enable 
the remotest recesses to be cleansed and disinfected at every dressing. It 
may happen that necrotic bone will be found, and in that case all such 
materials must be removed, but with great care in order to avoid the injury 
of living bone. 



CHAPTEE V. 

DISEASES OF THE JOINTS. 

The diseases of the joints of children differ from the same diseases in 
adults only in certain peculiarities depending chiefly upon differences in the 
maturity of the tissues involved. In the child the immature epiphyses of 
the long bones, the succulent cartilages and synovial membranes of the joints, 
afford all the conditions most favorable for the development of inflammatory 
affections. Injuries give rise to congestions over larger areas, and the vessels 
of these tissues become thereby enfeebled. These conditions favor the 
lodgement of infective particles in the circulation, and thus centres of sup- 
puration are more readily established. The tubercle bacilli from existing 
foci become implanted on the walls of the large and congested vessels and 
set up active disease. Even in the absence of traumatism the growing tis- 
sues of the joint are supplied with new-formed vessels which are extremely 
liable to intercept the tubercle bacilli. Tuberculosis of the joints, whether 
as a primary or secondary disease, is therefore far more frequent in children 
than in adults, and constitutes the prevailing form of joint diseases in the 
young. The liability of the epiphyses, as well as the joints themselves, to 
be the original centres of diseased action renders the exact diagnosis of joint 
affections more difficult in children than in adults. 

Acute serous synovitis in the child, except when due to injury or rheu- 
matism, is a comparatively rare affection. The part swells quickly ; effusion 
follows ; the pain is severe and the fever high. The acute symptoms are not 
as readily subdued as in the adult, and suppuration is very liable to super- 
vene, with ulceration of cartilages and destruction of the soft structures. In 
very mild cases dropsical effusions may distend the joint and require treat- 
ment. 

The treatment of the early stages should be absolute rest of the limb in 
a comfortable position, which will be semiflexed. The limb is best sup- 
ported on an angular splint, but in its absence it may be flexed over a firm 
pillow. It is also useful to attach a weight of one to three pounds to the 
foot in the manner usually employed in fractures, which relieves pain by 
slightly separating the joint surfaces. Cold applications in the form of an 
ice-poultice or an ice-bag are very important, but they must be continued 
without any intermission. The first effect of the cold is often painful, but 
when the cold penetrates the joint the pain subsides. The effect of the cold 
should be carefully watched, and if the pain continues, and especially if it is 
increased by the cold, the application should be removed. Evaporating 
lotions may be substituted. When the inflammation subsides efforts should 
be made persistently to restore the functions of the joints if they have been 
impaired. Passive motion, after the application of cloths wrung out of hot 



DISEASES OF THE JOINTS. 553 

water, is most useful. If fluid accumulates passively in the joint, small and 
repeated blisters, with compression, is the best treatment. 

Acute suppurative synovitis is marked by a higher grade of severe 
symptoms. The pain is greater, the fever higher, and the patient shows 
marked loss of flesh. When the evidences of the presence of pus are recog- 
nized, incisions for its evacuation should be promptly made. Before the 
period of antisepsis such incisions were delayed until the purulent collection 
so distended the soft tissues as to threaten spontaneous opening. In such 
cases the infiltration of tissues was very great, and often destructive. With 
the proper employment of antiseptic preparations not only no harm comes by 
the exposure of the cavity of the abscess by incision, but, on the contrary, 
great relief follows, and frequently the process of recovery dates from the 
operation. To accomplish all the good possible the pus must be thoroughly 
evacuated, and the joint must be treated as an abscess-cavity — viz. disinfec- 
tion must be thorough, the removal of necrotic tissues carefully effected, the 
drainage complete, and antiseptic dressings properly applied. The subse- 
quent treatment must be governed by the developments as they occur in the 
progress of the case. 

Case. — A boy, aged one year, has suffered five weeks from tenderness, pain, and, 
finally, swelling of left hip : has emaciated rapidly ; all movements of left thigh 
cause screaming. Child fell from arms of nurse a few days before first symptoms. 
Fluctuation was apparent, and an exploratory operation was performed, evacuating 
a large amount of pus. The head of the femur was found separated and was re- 
moved, with much broken-down bone-structure. The cavity was cleared of all 
diseased tissues and well drained. Improvement followed, and the child eventually 
recovered with a fairly good limb, but with some shortening. 

The tubercular affections of the joints of children are usually of a chronic 
character. They are recognized under several titles, as chronic or fungous 
arthritis, strumous arthritis, and tumor albus. 

The disease may begin in the synovial membrane or in the extremity of 
the bone entering into the joint. When the infection locates in the synovial 
membrane the tubercle bacilli are derived from the circulation. Several 
varieties of tubercular synovitis have been described, but clinically two are 
noticeable. The tubercle-nodule first appears in the synovial membrane 
and spreads over that structure ; as granulation progresses one of two pecu- 
liarities will be noticeable in this fungous synovitis: 1, the membrane may 
become pulpy throughout without effusion, giving the true tumor albus, or 
white swelling, with its characteristic deformity of the joint, and later back- 
ward and outward dislocation of the tibia ; 2, or there may be an effusion into 
the joint without deformity, and suppuration may follow, terminating in 
destruction of the granulations and perforations of the capsules. In the 
primary osteal form the joint becomes involved by the extension of the dis- 
ease through the epiphysis. The disease may therefore progress for a 
considerable period without any unusual symptoms at the joint. 

The cause of the disease in the vast majority of cases is some form of 
injury, often very slight, for severe injuries protect the joint by the severe 
inflammation which follows. 

The diagnosis between a primary osteal and a primary synovial tuber- 
culosis of the joint is often difficult. The former is four times as frequent 
as the latter at the knee, hip, and elbow. The most reliable symptom of 
osteal tuberculosis is the presence of tender points beyond the joint. If the 
disease is synovial, the symptoms depend upon the form of inflammation. 
If it is plastic and without effusion (cartes sicca), the progress is slow, and is 
detected by the pain, gradual stiffening of the joint, and slight roughness of 
the joint-surfaces. Or there may be effusion into the joint, which then be- 



554 LOCAL DISEASES. 

comes gradually distended, with distinct fluctuation. Finally, the granula- 
tions may become of large size, so as to distend the joint like an effusion, 
and may involve the tissues around the joint until it assumes a spindle shape, 
while the skin becomes dense and white, forming the true white swelling. 
The seeming fluctuation is deceptive, as will appear on using a hypodermic 
needle. Pain is variable and not reliable. Deformity occurs only when the 
tissues of the joint are weakened or destroyed. 

The prognosis of joint tuberculosis is favorable. Its curability depends 
upon the intensity of the infection and the resistance of the patient. It 
may terminate in recovery where the infection is limited and the patient is in 
good condition, but the joint is liable to be impaired in motion. The other 
forms are amenable to. and largely curable by, surgical treatment. 

The treatment of tuberculosis of the joints, when undertaken at an 
early period, should consist in immobilizing the part and improvement of the 
general health. Plaster of Paris is for most joints a useful appliance, and 
the limb should be fixed in such position as will render it most serviceable 
should ankylosis occur. If the joint is distended with fluid, antiseptic 
aspiration should be performed, followed by pressure, to prevent a return of 
the effusion. Injections of iodoform have been successfully used in the form 
of an ethereal solution, 1 part to 20 ; or in glycerin and alcohol ; or in 
glycerin, water, and mucilage of gum arabic. making a 10 per cent, solution. 
If the disease affects only the synovial membrane, and not the bone, excision 
of the diseased structures (arthrectorny) is the proper method of radical 
treatment. The opening of the joint must be by an incision which com- 
pletely exposes every part and recess. If the bone is involved, the operation 
must extend to the curetting of all the foci in the joint-surfaces of the 
bones, and, if necessary, to a removal with the saw of the articular ends of 
the bones. In all these operations every particle of tuberculous material 
must be scrupulously removed. 

The Shoulder-joint. 

The shoulder-joint is liable to inflammation from injury, or the extension 
of the disease from neighboring parts, or tuberculosis. It may become sec- 
ondarily affected when other joints are involved or after exantheins. 

The simple acute form of inflammation is extremely rare. The shoulder 
rapidly enlarges, forming on the anterior part a globular tumor, painful on 
pressure or when the arm is moved. The temperature is not high if the 
shoulder only is involved. 

The treatment must consist in supporting the arm in a sling so adjusted 
as to sec are quiet to the joint, without pressure of the joint-surfaces together 
or dragging. Evaporating lotions are the most useful as well as convenient 
applications. The inflammation usually subsides within a few days, and 
leaves no other complications than a stiffness which is soon overcome. 

The tubercular form of inflammation of the shoulder-joint in children is 
also rarely met with. It may first appear as a synovitis, but often the bone 
is primarily affected. It progresses as a chronic disease usually, but tends to 
ultimate suppuration and the formation of sinuses, through which dead bone 
can be detected. 

The early treatment consists in placing the joint at perfect rest. If 
pus forms, evacuation, by free incision and the removal of dead bone, must be 
promptly effected. The cavity should be curetted and all diseased structures 
cut away. If the head of the humerus is seriously involved, excision may 
be necessary. The general health must be sustained by improving the sur- 
roundings of the patient and the judicious employment of tonics. 



DISEASES OF THE JOINTS. 555 

Case. — A girl, aged three years, began to show symptoms of disease of the left 
shoulder-joint. At first there were only stiffness and pain on moving the arm, espe- 
cially forward over the chest ; her general health was impaired ; at times there was 
some fever. The arm was fixed by a pasteboard splint applied to the flexed elbow 
and held in position by a sling. Oleate of mercury was applied. At the end of 
four months fluctuation was discovered at the inner edge of the insertion of the 
deltoid, and on opening the swelling curdy material was discharged. On explora- 
tion the probe passed upward to the joint, but no bare bone was detected. After 
several weeks of treatment the joint was laid open and the head of the humerus was 
found partially destroyed. The bone was excised at the anatomical neck, after which 
recovery progressed favorably. The subsequent history of the child showed a resto- 
ration of most of the functions of the arm. 

The Elbow-joint. 

The elboic-joint is liable to the same forms of inflammation as the shoulder, 
but. being of more complicated structure, the results are liable to be crippling 
to the functions of the forearm. Synovitis may result from the ordinary 
causes which produce it in other joints, and should be treated by rest in the 
semiflexed position, the part being supported by a well-padded pasteboard 
angular splint. 

If the affection of the joint assumes the chronic form, the original focus 
of inflammation was probably located in one of the condyles of the humerus. 
The limb becomes fixed in a flexed position, and the tissues infiltrated. The 
enlargement of the joint assumes a spindle shape, finally fluctuates, and on 
opening the abscess pus, mixed with curdy, cheesy masses, is discharged. The 
cartilage is often found removed and the bones carious. 

If the case comes under treatment in the early stage of the disease, the 
joint must be fixed in a flexed position by an angular splint. Local appli- 
cations are of little service. Tonics, nourishing food, and good air are of im- 
portance with reference to the final results. When the presence of pus is 
determined operative interference is imperative. Incision should be made at 
the point of fluctuation, and then the joint should be thoroughly explored. 
It is often possible, by careful exploration through longitudinal incisions on 
the external and internal aspects of the joint, so to remove diseased tissues 
and to curette carious bone-surfaces as to leave the joint free from diseased 
structures, and in a condition for recovery with a comparatively useful joint. 
If, however, the disease of the bones of the joint involves the epiphyses, ex- 
cision must be practised. The lateral incisions are the best adapted to pre- 
serve the soft structures of the joint from impairment. In the enucleation 
of the diseased bone the periosteum should be preserved. Frequently this 
membrane will be found very dense and easily separated from the bone. 
While it is important to remove all of the necrotic bone, care should be taken 
not to sacrifice any more of the joint extremities than is absolutely necessary. 
At as early a period as possible passive motion should be commenced in order 
to recover as much flexion as possible. 

Case. — A boy, aged four years, injured the right elbow-joint by a fall six months 
previously. There was moderate swelling, which soon subsided. On being lifted 
by the right hand he complained of pain ; the joint became tender : swelling slowly 
increased. When first seen the elbow was largely swollen, very sensitive on slight 
movement, and crepitus was discovered. An incision was made along the external 
margin of the elbow, giving escape to pus and some curd-like masses. The external 
condyle of the humerus was uncovered, and the olecranon was also involved on its 
joint-surface. A second longitudinal incision over the internal condyle exposed the 
carious condition of that bone. The periosteum was raised and the joint-ends of 
the humerus exposed. A small portion of the bone was removed from each condyle 
with a fine narrow saw, the wound cleared of some fragments of tissue, and anti- 
septically dressed. Recovery followed slowly, and by persistent efforts flexion was 
secured to the extent of enabling the patient to feed himself with that hand. 



556 



LOCAL DISEASES. 



The Wrist-joint. 

The wrist-joint is rarely the seat of simple synovitis. When affected, a 
well-padded splint should be applied to the dorsum of the forearm and hand, 
and the forearm must be supported in a sling which includes the hand. Evap- 
orating lotions seem often to relieve the inflammation in some degree, but 
they are troublesome dressings to maintain. By maintaining complete rest 
the inflammation usually subsides slowly, but is likely to leave some stiffening 
of the joint, which may be overcome by gentle passive motion. 

The tubercular form of disease is liable to be serious, as the inflammation 
often involves the carpal joints. The swelling occurs slowly, and is not as 
strictly limited to the wrist-joint as synovitis ; it finally assumes a baggy or 
cedematous condition, often involving the entire carpal region. Finally, rough- 
ness of the wrist-joint, and perhaps of some of the neighboring carpal joints, 
is detected, showing a disorganization of the joint-structures. Complete rest 
to the wrist and carpus must be secured and maintained by well-padded ante- 
rior and posterior splints, and the general health improved by tonics and nutri- 
tion. Pus must be evacuated by incision when detected, and the wound well 
drained. If the disease involves the bones of the wrist or of the carpus, 
excision must be performed. This operation should be performed with great 
care, in order to preserve the parts in such relations as to secure a useful 
limb, and still all of the tuberculous tissues must be removed. If the dis- 
ease is intelligently treated from its first inception, no other excision may 
become necessary than the removal of the joint-end of the radius. In this 
case the movements of the joint may be very well preserved. But usually 
the carpus is also involved, and then the operation becomes much more com- 
plicated. The approved methods of operation are as follows : 



(a) Listers excision of the entire wrist consists of a series of operations, each 
of which must be executed with scrupulous care, as follows : Break down adhesions 
of tendons by freely moving all the articulations of the hand ; commence the first 

incision at the middle of the dorsal 
Fig. 168. aspect of the radius, A (Fig. 168), on a 

level with the styloid process ; carry it 
toward the inner side of the metacarpo- 
phalangeal articulation of the thumb, 
running parallel in this course to the 
extensor secundi internodii ; on reach- 
ing the line of the radial border of the 
second metacarpal bone carry it down- 
ward longitudinally half the length 
of the bone, the radial artery lying 
farther to the outer side of the limb ; 
detach the soft parts from the bone at 
the radial side of the incision, the knife 
being guided by the thumb-nail ; divide 
the tendon of the extensor carpi radialis 
longior at its insertion into the base of 
the second metacarpal bone, and raise 
it along with that of the extensor carpi 
radialis brevior previously cut across, 
and the extensor secundi internodii, 
while the radial is thrust somewhat out- 
ward : separate the trapezium from the 
rest of the carpus by cutting forceps ap- 
plied in the line with the longitudinal 
part of the incision : leaving the trape- 
zium in position until the rest of the carpus is taken away, dissect the soft parts 
on the ulnar side of the incision from the carpus as far as convenient, the hand 




Excision of wrist : .4, Lister's radial incision ; 
B. Lister's ulnar incision ; C, Oilier ; D, 
Boeckel. 



DISEASES OF THE JOINTS. 557 

being bent back to relax the extensor tendons of the fingers; commence the second 
incision, B (Fig. 16S), on the palmar surface, at least two inches above the end of 
the ulna, immediately anterior to the bone, and carry it downward between the 
bone and flexor carpi ulnaris, and on in a straight line as far as the middle of the 
fifth metacarpal bone on its palmar aspect ; raise the dorsal lip, cut the extensor 
carpi ulnaris at its insertion into the fifth metacarpal bone, and dissect it from 
its groove in the ulna without isolating it from the integuments ; separate the 
extensors of the fingers from the carpus, and divide the dorsal and internal lateral 
ligaments of the wrist-joint; leave the connections of the tendons with the radius 
undisturbed : now clear the anterior surface of the ulna by cutting toward the bone, 
avoiding the artery and nerve ; open the articulation of the pisiform bone, and sepa- 
rate the flexor tendons from the carpus, the hand being depressed to relax them ; 
clip through the base of the process of the unciform bone with pliers, but avoid 
carrying the knife farther down the hand than the bases of the metacarpal bones ; 
divide the anterior ligament of the wrist-joint, separate the carpus from the meta- 
carpus with cutting pliers, and extract the carpus with sequestrum forceps through 
the ulnar incision, dividing any ligamentous attachments ; the articular ends of the 
radius and ulna may be protruded at the ulnar incision and excised ; divide the 
ulna obliquely with a small saw so as to take away the cartilage-covered rounded 
part over which the radius sweeps while the base of the styloid process is retained ; 
clear the radius sufficiently to remove the articular surface ; if the caries is slight, 
remove a thin slice without disturbing the tendons in their grooves on the back of 
the bone ; clip away the articular facet of the ulna with bone forceps applied longi- 
tudinally ; if the caries is extensive, remove freely all the diseased bone with pliers 
and gouge ; examine the metacarpal bones and excise the articular surfaces only 
if they are sound, and more extensively if diseased ; next seize the trapezium with 
strong forceps, and dissect it out without cutting the tendon of the flexor carpi 
radialis, and excise the end of the metacarpal bone ; clip off the articular facet of 
the pisiform bone, and, if sound, leave the remainder in position ; close the radial 
incision firmly throughout with sutures, and also the end of the ulnar incision, but 
the middle must be kept open by pieces of lint introduced lightly to give support 
to the extensor tendons and afford free escape of discharges. 

(b) In BoeckeVs operation the incision may be made from the middle of the 
ulnar border of the metacarpal bone of the index finger upward to the middle of 
the dorsal surface of the epiphyses of the radius, D (Fig. 168), crossing to the ulnar 
side of the extensor carpi ulnaris at its insertion into the base of the third metacar- 
pal bone, and dividing the dorsal ligament of the carpus between the tendons of the 
long extensor of the thumb and the extensor indicis ; the soft parts being raised 
through the incision by careful manipulation of the hand, the carpal bones may be 
removed, one by one, by dividing the ligaments which bind them together and to 
other bones. 

(c) Oilier makes an incision, C (Fig. 168), from an inch below the styloid pro- 
cess of the radius upward along the external border of that bone, to a sufficient ex- 
tent ; a branch of the radial nerve being preserved, the extensor tendons of the 
thumb are exposed and drawn aside and the insertion of the superior longus ex- 
posed. With the periosteum denude the end of the radius and bend the carpus 
forcibly inward, dislocating the head of the radius outward. After separating the 
fibrous attachments excise the requisite amount. The end of the ulna may be 
reached through the same wound, or an incision along the inner border will 
expose it. 

The after-treatment must be pursued with due recognition of the fact 
that the new joint at the wrist is produced by an approximation of the bones 
of the forearm and of the metacarpus, partly by shortening of the limb and 
partly by the growth of new bone from the divided ends ; with proper care 
perfect symmetry of the hand can always be ensured ; for as the radius and 
ulna above and the metacarpus below are divided in parallel lines, the shrink- 
ing of the new material between them draws the hand equally upward toward 
the forearm ; the surgeon should aim to maintain flexibility of the fingers by 
frequently moving them, and at the same time to procure firmness of the 
wrist by keeping it securely fixed during the process of consolidation. These 



558 LOCAL DISEASES. 

indications are met by placing the limb on Lister's splint (Fig. 169), which 
consists of an obtuse-angled piece of thick cork attached to a splint, with a 
cross-bar of cork attached to the under surface about the level of the knuckle ; 

Fig. 169. 




Hand after excision of wrist, laid in splint. 

on the splint the hand lies semi-flexed, its natural position, the fingers mid- 
way between the extremes of flexion and extension into which it is necessary 
to bring them in the daily passive movements ; the thumb is to be kept from 
the index finger by a pad of cotton maintained between them ; flexion and 
extension of the fingers should be commenced on the second day whether 
inflammation has subsided or not, and continued daily, each finger being 
flexed and extended to the fullest degree possible in health, care being taken 
that the metacarpal bone concerned is held steady ; pronation and supination 
must not be neglected, and as the wrist acquires firmness flexion and exten- 
sion, adduction and abduction, should be occasionally encouraged ; passive 
motion must be continued until there is no longer a tendency to contract ad- 
hesions. 

The Hip -joint. 

The hip-joint is liable to all the forms of disease peculiar to other joints, 
but in a very different ratio. 

Simple synovitis, uncomplicated by other affections, is rare and difiicult 
of correct diagnosis. It is most apparent when it immediately follows an 
injury. It soon subsides with rest and extension of the limb, the only treat- 
ment applicable. 

The acute suppurative forms of inflammation of the hip-joint are epi- 
physeal in origin and run the course of osteomyelitis. The joint becomes 
secondarily affected. The swelling is considerable, the pain severe, especially 
on moving the limb, and the temperature high. 

The treatment consists in extension of the limb by a weight at the foot, 
perfect rest, and, when pus is detected, free incision. It often happens that 
necrotic bone is discovered, which must be removed, even to the extent of 
excision of the entire head and neck of the femur, if necessary, in order to 
leave the cavity free from dead structures. Recovery usually follows, and a 
useful limb is often secured. Convalescence is always prolonged according 
to the extent of damage done to the bone and the general health of the 
patient. The joint must be protected from motion by the hip-splint, or by 
extension while the patient is confined to the recumbent position, until the 
consolidation of the cavity is well advanced, and then movements must be 
restricted for a considerable period. Usually the patient should be confined 
in bed, with extension at the foot, until the wound is granulating, when 
he can resume the hip-splint. 

The tubercular form of hip disease is by far the most common, and 
demands the most intelligent care on the part of the practitioner. It was 



DISEASES OF THE JOINTS. 559 

formerly one of the most painful and destructive surgical diseases of child- 
hood, but at the present time it has become amenable to treatment, so that 
it may not only be rendered comparatively free from pain, but recovery may 
be secured with a useful limb. In a total of 277 cases, 142 were males and 
135 were females ; 9 were over fourteen years of age, and 261 were under 
that age. Sex is therefore unimportant as a factor in the liability to the 
disease, but it is peculiarly a disease of childhood. Tubercular hip disease, 
therefore, should be thoroughly understood by the practitioner. 

The disease may commence in the synovial membrane, or in the acetabu- 
lum, or in the head of the femur. It is more frequently of osteal origin, 
and extends to the joint secondarily through the epiphysis. Four forms of 
tubercular synovitis have been recognized, the difference depending upon the 
formation of the granulation tissue. It is, however, difficult to distinguish 
the special form of the disease at an early period, nor is it of practical im- 
portance, as the treatment of the several forms does not differ. In all cases 
the progress of the affection, when of synovial origin, is more liable to be 
acute than when of osteal origin. 

The symptoms of both synovial and osteal tuberculosis of the hip 
depend upon the progress of the disease. It usually follows an injury to 
the hip. If the inflammation is acute, it is attended with great intolerance 
of movements of the limbs, fever, swelling of the hip, emaciation, and dis- 
turbed sleep owing to the spasms of the muscles at night. Pus forms at an 
early period, with great tumefaction of the region of the hip. In the sub- 
acute form all of the preceding symptoms are less marked. The pain does not 
prevent the child from playing, and is often referred to the inside of the 
knee ; the starting of the limb at night is less constant ; the flexion is less 
restrained, but cannot be carried to an extreme degree ; the swelling comes 
on slowly, and many months may elapse before the child finally ceases to 
use the limb. But the diseases may be more chronic still, especially when 
of osteal origin. It frequently happens that there is a long period of slowly 
progressing trouble at the hip which escapes the attention of even the physi- 
cian. The pain is so slight and occasional that it is never complained of; 
very often it is at the knee, and may follow a fall on that part, thus the more 
readily deceiving the attendant ; the patient does not give up active exer- 
cise, and there is nothing to indicate any affection at the hip. It is only 
after a long period that the symptoms become so pronounced as to attract 
notice to the actual spot. The practitioner cannot be too careful in these 
cases, for on a correct diagnosis will depend the recovery of the patient with 
a useful limb. 

The diagnosis of hip disease is liable to great errors. If seen at an 
early stage, when the disease is of a chronic form and the symptoms slight, 
it has been mistaken for an affection of the knee, of the sacro-iliac joint, for 
chronic rheumatism, rickets, and hysteria. In advanced stages, when the 
swelling is great, it has been treated as acute rheumatism, periostitis of tro- 
chanter, abscess of glandular, psoas, gluteal, or iliac origin, and other dis- 
eases. 

Pain is a most uncertain and often misleading symptom. The patient 
may vaguely admit that he has pain, but he often refers it to other places 
than the hip. These pains are often called " growing pains." The} T may be 
in the region of the pelvis, down the thigh, at the knee or the ankle. They 
sometimes remain so persistently at the knee that the disease has been located 
in that joint, and applications have been made to the knee for its relief. 
Efforts to elicit symptoms of pain in the joint by pressure over the trochan- 
ter or on the foot generally fails ; it is only by extreme abduction or adduc- 
tion that the patient gives evidence of being injured. Disturbed sleep, from 



560 



LOCAL DISEASES. 



starting of the limb, is sometimes a symptom which attracts little atten- 
tion. Lameness is also present, but often it is so slight that neither the 
patient nor immediate relatives recognize its existence for a considerable 
time. It is, however, significant of impairment of the movements at the 
hip-joint. At length it becomes apparent, owing to permanent flexion of the 
thigh and the effort of the patient to avoid the jar caused by stepping on 
the heel. The swelling occurs later and is a most important factor in the 
diagnosis. It may appear very early in front, and then indicates distention 
of the capsule with fluid. This, with accompanying symptoms, points unmis- 
takably to the hip-joint as the seat of trouble. Later the tissues around 
the joint become involved, and finally the capsule ruptures, when the swell- 
ing becomes most marked behind the trochanter. 

The attitude of the patient should be carefully studied. Place him on 
the back, and, grasping the leg below the knee, slowly flex each thigh on 
the body. The unaffected joint will permit the thigh to be pressed down 
firmly upon the abdomen (Fig. 170), but when an effort is made to flex in a 

Fig. 170. 




Sound thigh flexed on abdomen for ascertaining exact amount of deformity. 

similar manner the opposite thigh, the joint of which is affected, the flexion, 
even in the earliest stages of disease, is suddenly arrested, and the child 
resists all further attempts at flexion. A very simple method of making 
this test is to request the child to touch his nose to his knee ; he accomplishes 
the feat readily with the healthy limb, but fails with the diseased limb or 
succeeds with difficulty, though he makes great efforts to effect the object. 
This is one of the most reliable evidences of hip disease, and can readily be 
made. A second test of a similar kind should be made at the same time. If 
the patient lies on a smooth, hard surface, and his spine rests on it, the flexion 

Fig. 171. 




Limb brought down, but loin arched (Owen). 



of the thigh, caused by the fixation of the joint, will at once elevate the knee 
of the affected limb. If, now, the knee is pressed down so as to touch 
the surface, the spine becomes arched (Fig. 171), owing to the fixation of 
the hip-joint. The same test can also be applied by placing the patient in 



DISEASES OF THE JOINTS. 



561 



Th< 



Fig. 172. 



a prone position and slowly elevating the leg, seizing it at the ankle, 
healthy limb will move readily to the fullest extent 
backward, while the affected limb admits of but 
limited backward motion. 

Atrophy of the limb is a very early sign of hip 
disease. The points of measurement are the middle 
of the upper thirds of both the thigh and leg. At 
these points we measure the muscles at their largest 
development. If there is atrophy of the limb which 
is suspected, the fact is of value only in connection 
with the other signs and symptoms. Of more im- 
portance in diagnosis is the wasting of the muscles 
of the affected part. The hip assumes a flattened 
appearance, and the usually well-marked trans- 
verse (Fig. 172) gluteal fold disappears or takes an 
oblique direction downward and outward. As the 
disease advances the symptoms and appearances be- 
come more marked and significant. In the first stage 
the limb emaciates, and the thigh becomes flexed ; in 
the second stage the limb is abducted and rotated 
outward : and in the third stage it is adducted and 
rests on the other thigh. 

Sayre explains the pathological conditions as fol- 
lows : The cavity of the joint becomes distended 
with fluid, and the affected limb is slowly abducted 
and apparently lengthened ; subsequently suppura- 
tion occurs in the joint, the capsule ruptures, and 
the limb becomes adducted, and it appears to have 
undergone a process of shortening. These differences in length are, 
ever, only apparent, owing to an inclination of the pelvis. 

Owen remarks: "As soon as the pelvis is brought square with the spine and 
the lumbar vertebrae are all flat upon the table, the amount of deformity may be 
accurately determined. Apparent shortening is then explained, and a limb which 
hitherto might have been considered to be in good position maybe found of normal 




Fig. 173. 




length, but flexed and greatly adducted. The schemes represent (a) pelvis and 
lower extremities in every respect normal ; (b) disease of the left hip-joint, tilting 
of the pelvis, the left limb being apparently shortened, but in the normal line ; (c) 
shows how, by the squaring of the pelvis, the limb has been brought down and 
found greatly adducted, yet of normal length : (d) represents disease of the left 
joint, the pelvis having been tilted (possibly dropping from want of the accustomed 
support), so that the left extremity seems increased in length, though still in normal 
36 



562 LOCAL DISEASES. 

parallelism. But on bringing the transverse line of the iliac crests at right angles 
with the spinal column, as in (e), the left limb is found of normal length, but 
greatly abducted. 

" The position of the limb, therefore, marks three stages in the progress of the 
disease, and becomes a valuable diagnostic sign: viz. 1, there is simple flexion, 
with perhaps slight abduction and outward rotation ; 2, flexion with marked rota- 
tion outward, and abduction with apparent lengthening ; 3, flexion, rotation inward, 
adduction and apparent shortening. : " 

As the case progresses the hip becomes flattened and the gluteal fold is 
lost or becomes very oblique. The patient suffers at night from starting 
pains, and during the day maintains the limb in a fixed position, partly by 
muscular force and partly by the thickening of tissues. The pain varies 
much ; it may be absent in severe cases or intermittent, and is liable to 
change from one locality to another as to the thigh, knee, leg, and feet. Its 
diagnostic value is very slight. Finally, the child assumes a perfectly quiet 
position, and resists every effort to move the limb. This peculiarity marks 
the last stages of the disease. The swelling, which was at first most marked 
in front of the thigh, now becomes prominent over the trochanter, and indi- 
cates suppuration in the joint. The abscess at length opens, usually behind 
and below the trochanter, and afterward at other points, following the course 
of the muscles. On moving the limb, grating may now be felt if the joint is 
destroyed, owing to the escape of the pus. which by distention prevented 
the head of the femur from free contact with the acetabulum. From this 
time the limb remains permanently flexed and adducted. 

In cases which have progressed uninterruptedly the head of the femur 
may be destroyed or may escape from the acetabulum. During this period 
of suppuration the health of the patient deteriorates ; there is septicaemia, 
and often pyaemia ; emaciation increases, and the larger number die of ex- 
haustion if the disease is allowed to pursue its course to its termination. Those 
who survive the natural processes are doomed to have a crippled limb for life. 

The prognosis of hip disease under intelligent treatment is extremely 
favorable. It can be arrested in the early stages by modern methods of treat- 
ment, and the general health preserved. In the later stages it can be ren- 
dered painless and the patient can be protected from loss of health. Finally, 
in the most advanced and unfavorable cases when first brought under treat- 
ment life may be preserved and a comparatively useful limb secured. 

The treatment of hip disease is now based on rational principles, and 
can be successfully carried out by every practitioner. At every stage of the 
case the result aimed at in this treatment is the protection of the diseased 
structures from injury and the promotion of the health of the patient. These 
conditions are not secured by rest in bed. It is true that rest will prevent the 
shock and impact of walking, but it will not save the joint from the injury 
caused by the spasm of the muscles and the movements of the limb. Proper 
protection can only be secured by such traction of the limb as will relieve all 
pressure of the head of the femur on the joint-surfaces. This can be effected 
by the weight and pulley when the patient is confined to his bed, and by the 
hip-splint when he is allowed to move about. 

The employment of these appliances should not be delayed after the diag- 
nosis of hip-joint disease is made, nor should they be intermitted until the 
cure has been perfected. In the early periods of a very chronic case it will 
be difficult to persuade the patient and friends to submit to this plan of treat- 
ment. But the practitioner will be culpable who does not firmly insist upon 
the application of well-adjusted and efficient apparatus. The period during 
which the hip-splint will be required, even in the most favorable cases, will 
exceed a year, and more often eighteen months or two years. 



DISEASES OF THE JOINTS. 



563 



The importance of the hip-splint in tubercular disease of the joint cannot 
be over-estimated. It enables the patient to take the necessary amount of 
exercise in the open air to preserve his general health, while the affected joint 
is placed in a condition of rest from its ordinary functions. Frequently the 
child is enabled to resume many of those sports in the open air which give zest 
to exercise and are essential to health. There is no single device in practical 
surgery which more exactly meets all its indications than the ordinary hip- 
splint. It is doubtful if in the whole realm of inventions a greater service 
has been rendered to an individual class of patients than this splint has ren- 
dered to those afflicted with hip disease. It has not only rescued vast num- 
bers of children from a prolonged and painful sickness and a lingering death, 
but it has saved them from pain and suffering. When, therefore, the disease 
is recognized as involving the structures entering into the hip-joint, whether 
as a synovitis or an osteomyelitis, this treatment should be commenced. It 
is generally better to employ, for a time, extension of the limb while the 
patient is in bed before permanent apparatus is applied. The patient should 
accordingly be placed in the recumbent position, with a weight at the foot to 
make such extension as will counteract muscular contraction. The rubber 
plaster should be selected, and cut in strips about an inch and a half wide and 
of sufficient length to extend to the middle of the thigh and form a loop below 

Fig. 174. 




Bed for extension. 

the foot. The bed should be firm, the foot being elevated slightly (Fig. 174) 
and the surface smooth. The weight need not exceed four to six pounds. 
At first the extension should be in the direction of the flexed thigh, but grad- 
ually it should assume the straight position. Usually great relief to all of 
the symptoms follows the use of the weight. This is due to the traction of 
the muscles of the thigh, which prevents the undue pressure of the head of 
the femur on the joint attending their spasmodic contraction. 

But confinement to the bed soon impairs the patient's health, and hence 
the necessity of supplying an apparatus at an early period which enables him 
to take proper exercise, while it protects the joint from injury. The hip-splint 
meets every indication now present. The following is a description of the splint : 

The splint (Fig. 175) extends from the sole to the crest of the ilium, where it is 
connected to a pelvic band by a joint allowing flexion and extension, abduction and 
adduction, but properly regulated. Extension is made by means of adhesive plaster 
applied to the leg and attached by buckles to the two ends of a leather strap fastened 
to the foot-piece ; counter-extension is made by means of two perineal pads fastened to 
the pelvic band with straps and buckles ; at the knee-joint is a movable cross-piece for 
attaching a leather cap to steady and support the knee ; at the bottom of the instru- 
ment is a foot-piece with a leather sole attached, to prevent jar in walking : a leather 
strap, passing under the foot through apertures in the foot-piece, turns up an end on 
each side of the ankle, and fastens to buckles in adhesive strips, which prepare as 
follows : Cut two pieces of strong plaster, to reach from the middle of the thigh 
nearly to the ankle and two inches wide ; attach a strong saddler's buckle to the 



564 



LOCAL DISEASES. 



lower end of each ; apply the plasters against the lateral aspects of the leg, begin- 
ning about two inches above the internal and external malleoli with the ends hav- 
ing the buckles attached ; a few turns of roller bandage are then made around the 
ankle, just under the lower ends of the straps, to protect the flesh under the buckles, 
and then continued over the strips on the whole limb. The patient should be laid on 
his back, and great care ought to be taken that the pelvis is not inclined forward by 
contractions of the flexor muscles ; should this be the case, elevate the leg until the 
lumbar vertebrae come near the couch and the spinal column assumes its normal 
shape ; the instrument is then applied. The pelvic band ought to be loose enough 
to allow the pelvis to move freely in it ; the anterior superior spine of the ilium 
ought to be above the pelvic band (Fig. 176) ; in applying the ankle-straps leave a little 



Fig. 175. 



Fig. 176. 





Hip-splint. 



Hip-splint applied. 



space between the foot and the foot-piece, so that in standing or walking the weight 
of the patient does not rest on the leg, but on the instrument ; the perineal straps 
must be so adjusted that the patient sits firmly and comfortably upon them : when the 
apparatus is adjusted tighten the perineal straps until the patient gives evidence that 
the strain is sufficient. The attendant should be instructed to keep all the straps as 
tense as the patient will bear without complaint. 

The hip-splint, properly adjusted, should be entirely comfortable, and should 
enable the patient to walk with comparative ease. In ordinary cases of hip dis- 
ease of osteal origin the splint must be worn for eighteen months to two years. 

Case. — J. C , a boy, aged nine years, strumous, developed tubercular epiph- 
ysitis of the neck of the femur. "When first seen the left leg was flexed and slightly 
abducted; the pain constant; sleep was disturbed ; there was marked emaciation. 
The hip-splint was applied, and he soon began to walk freely ; the pain disappeared, 
and he began to take on flesh. He wore the splint twenty months, and during the 
time took active exercise. Latterly he played games of ball. All signs and symp- 
toms of hip disease meantime disappeared. 

The removal of the splint must be undertaken with great care, and only 
after all of the symptoms have disappeared for a considerable period. To 
determine the condition of the joint, the limb should be flexed, abducted, 
adducted, percussed, and rotated. The motions, especially flexion, will not 
be as free as are those of the healthy limb, but they will not be painful as 



DISEASES OF THE JOINTS. 565 

formerly. The splint should for a time be removed only at night, to be 
resumed in the morning before rising. Then it may be omitted while the 
patient remains in the house, and applied if he walks out, to prevent acci- 
dent. Finally, if the case progresses well, the intervals of use of the splint 
may be lengthened. If at any time there is a recurrence of symptoms, the 
splint must be resumed for a time. 

Abscess is likely to appear in the progress of the disease, and there has 
been much discussion as to the propriety of evacuating the pus. It is held 
that if the abscess is not disturbed it will be harmless, and may be absorbed, 
while if the cavity is opened, profuse suppuration is liable to be established, 
greatly to the detriment of the patient. Such reasoning is fallacious, in that, 
first, there is danger that the retained pus will infect the system as it invades 
new areas of cellular tissue ; and, second, the pus can be evacuated without 
endangering increased suppuration. The rule of practice should be to freely 
open abscesses which arise in the course of hip-joint disease, taking all need- 
ful antiseptic precautions. The result of such treatment is always beneficial, 
and in some instances is followed by immediate improvement. 

Case. — A. B , a lady, twenty years old, had been under treatment for hip 

disease one year, during which she wore the usual hip-splint. An abscess appeared 
four months before admission to the hospital, but it was not opened. It was now 
of large size, being most prominent behind the trochanter. She was greatly ema- 
ciated, had fever with irregular chills and sweats, and a rapid, feeble pulse. An 
anaesthetic was given on two occasions for an operation, but in both instances the 
heart failed, her face became purple and the respiration greatly embarrassed. A 
third attempt was preceded by securing partial intoxication with whiskey. The 
patient took an ounce of whiskey in half a pint of hot milk every hour, commencing 
at eight o'clock in the morning. At twelve o'clock she was talking foolishly ; her 
eyes were suffused, her pulse quiet at 96 beats per minute, her skin warm and 
natural, and her respirations full. She required but little of the anaesthetic, and 
during the operation her pulse continued at 96, without showing any signs of 
weakness, and the respirations remained unchanged. A large amount of pus was 
evacuated. The head of the femur had separated, and was removed, with much 
disintegrated bone. The general condition of the patient improved rapidly, and she 
made a good recovery. 

The abscess may not communicate with the joint, and in that case the 
cavity should be thoroughly curetted and packed with antiseptic gauze. 
The healing of the abscess-cavity generally progresses favorably. If how- 
ever, the abscess is connected with the joint or with diseased bone, the 
operation should extend to the removal of all dead structures, even to the 
extent of excision of the head of the femur. 

Aspiration of the distended capsule may be practised in the early stage 
of effusion. This condition is marked by a swelling over the joint and that 
feeling of elasticity which is due to the tense capsule. It is safer to make 
the puncture behind the trochanter than in front. Aspiration to remove a 
purulent collection during the progress of hip-joint disease is a waste of time. 
If the indications are that the head of the bone is seriously involved, 
excision will be required. An exploratory operation to determine the extent 
of the destruction of tissues should be deliberately undertaken, provision 
having been made to excise the necrotic bone. 

The extent of the resection should depend upon the amount of disease ; 
if limited to the head, that part alone should be removed ; if the neck is 
carious, the trochanter may still be preserved ; but if the latter is involved, 
the bone must be divided at the trochanter minor. 

The methods of operating are numerous, but the single incision, with sub- 
periosteal removal of the bone, most nearly meets the anatomical indication 
of the part. 



566 



LOCAL DISEASES. 



Fig. 177. 



Several arteries are distributed to this region — viz. the gluteal, sciatic, 
obturator, and circumflex, the only one which approaches the line of the 
incision near enough to be incised before dividing into branches of distribu- 
tion too small to give rise to noticeable hemorrhage is a twig of the internal 
circumflex, which at one-eighth to one-fourth of an inch from the insertion 
of the obturator externus breaks up into its terminal divisions ; this branch 

may be avoided by keeping the point of 
the knife well against the bone, and divid- 
ing the tendon of the obturator externus 
muscle in the digital fossa. 

Excision is as follows : The patient lying 
on the sound side, with a strong knife com- 
mence an incision, A (Fig. 177), at a point 
midway between the anterior inferior spinous 
process of the ilium and the top of the great 
trochanter •, carry it in a curved line over the 
ilium in contact with the bone, across to the 
top of the great trochanter ; extend it not di- 
rectly over the centre of the trochanter, but 
midway between the centre and its posterior 
border ; complete it by carrying the knife for- 
ward and inward, making the whole length of 
the incision four to six or eight inches, accord- 
ing to the size of the thigh ; if the periosteum 
has not been divided by the first incision, 
carry the point of the knife along the same 
line a second or third time ; an assistant sepa- 
rating the wound with the fingers or retractors, 
the great trochanter, b (Fig. 178), is exposed ; 
with a narrow, thick knife make an incision 
through the periosteum only at right angles 
with the first at a point an inch or an inch and 
a half below the top of the great trochanter, 
opposite or a little above the lesser trochanter, 
and extend it as far as possible around the bone, making sure that the periosteum 
is freely divided ; at the junction of the two incisions of the periosteum introduce 

the blade of the periosteal elevator, and grad- 
ually peel up the periosteum from either side 
with its fibrous attachments until the digital 
fossa has been reached ; with the point of the 
knife applied to the bone divide the attach- 
ments of the rotator muscle, and continue to 
elevate the periosteum, carefully avoiding 
rupturing it at any point : when the perios- 
teum is removed as far as necessary, adduct 
the limb slightly, depress the lower end of 
the femur sufficiently to allow the head of the 
bone to be lifted out only so far as is requi- 
site to permit its removal with the saw, g ; 
divide the bone just above the trochanter 
minor and remove the fragment ; if the head 
of the bone cannot be raised before division 
on account of the involucrum, saw the bone 
first and then remove the head ; if the shaft 
at the point of section is necrosed, expose 
and exsect more ; examine the acetabulum, 
and if found diseased remove all dead bone ; 
if perforated, the internal periosteum will be 
found peeled off, making a kind of cavity be- 
hind the acetabulum, and all diseased bone 
Passing chain-saw. must be very carefully chipped off down to 




Excision of the hip : A, Sayre ; B, Oilier. 




DISEASES OF THE JOINTS. 567 

the point where the periosteum is reflected from sound bone. Every part of the 
wound and all sinuses must be thoroughly cleaned of particles of bone and false 
membrane. 

For some time after the operation the patient must remain in bed. and 
extension of the leg by a weight should be continued, and not omitted until 
the hip-splint is resumed. As soon, however, as the wound has healed suffi- 
ciently to allow him to move about and without discomfort, the patient 
should resume his splint and continue to wear it until the tissues of the 
joint are consolidated. The amount of shortening which follows is very 
variable. Primarily, it depends upon the extent of the bone removed, but 
this does not affect it so greatly as does the treatment. If a suitable degree 
of extension of the limb is maintained, two important changes occur — viz. 
first, the femur continues to lengthen by the natural growth of the bone at 
the lower epiphysis ; and, second, the new structures which form at the seat 
of excision are extensive, and, becoming firmly attached to the bone, main- 
tain it in good position. It is very important, therefore, to maintain exten- 
sion, first, by a weight during the confinement of the patient to the recum- 
bent position, and when he is able to resume the splint, that should be faith- 
fully employed until the wound is firmly closed and perfected. The wound 
sometimes reopens and small fragments of bone are discharged '; this reopen- 
ing is occasionally due to an injury of the new tissues of the abscess- 
cavity. 

As recovery progresses the question of mobility of the limb becomes 
important. The tendency of the cicatrization of the new-formed tissues is 
to immobilize the upper end of the femur. If no effort is made to prevent 
this contraction and consolidation, immobility will become complete, and 
ankylosis at the hip will result. It is desirable, therefore, to commence 
slight passive motion at an early period, and gradually increase the mobility. 
If the limb has been shortened by excision of the head of the femur, a 
proper shoe should be applied. 

The Knee-joint. 

The large extent of the surfaces of the knee-joint, its complicated mechan- 
ism, and its exposed position render it peculiarly liable to inflammatory affec- 
tions. 

Acute synovitis is caused by injury. Its diagnosis is readily made, as the 
significance of the swelling, heat, and pain is at once appreciated. 

The treatment should be absolute rest, the limb being somewhat flexed 
over a pillow, and applications made of the ice-bag or of an ice-poultice. 
The disease is of short duration, but the patient must resume active use of 
the joint very gradually. 

Chronic synovitis, with the large collections of fluid which occur in the 
adult, is very rarely seen in the child. When it exists the child will be 
found to be in impaired health. 

The treatment must be directed to improvement of the health, and the 
application of such measures as will promote absorption. One of the most 
simple and effective methods is strapping. The straps should be applied in 
such manner as to compress the contents of its cavity firmly against the 
hard tissues, and not into recesses of the capsule. This is effected by placing 
the straps alternately above and below, and completing the process by apply- 
ing the last over the centre of the joint. They should not meet posteriorly, 
in order not to interrupt the circulation in that region. Painting the knee 
with strong iodine frequently is sometimes useful, as are small blisters, often 
repeated. 



568 LOCAL DISEASES. 

Tubercular disease of the knee may begin in the synovial or bony tissues, 
the latter being to the former in the proportion of 3 to 1. In the early 
stages the former is recognized as a degeneration of the synovial membrane, 
cartilage, and the bone-surfaces through a process of granulation. It usually 
proceeds slowly, with no severe symptoms. The destruction of tissue is 
extensive. In the early stages of the affection two conditions may be found. 
In one there is little or no effusion and the knee is pulpy, owing to the 
amount of granulation tissue. The joint-ends of the bone seem to be en- 
larged, but this condition is due to the dense thickening of tissues by gran- 
ulations. This is the " white swelling " of early writers, and is followed by 
such deformities as flexion, backward dislocation, outward rotation. In the 
other form effusion takes place without deformity, and fluctuation is notice- 
able. If the disease is of osteal origin, the primary swelling is not so 
directly in the line of the joint, but in the vicinity of the epiphysis involved, 
and tenderness may be detected on this line. 

The progress of the acute disease is that of an osteomyelitis, the joint 
becoming involved secondarily by the penetration of the pus from the focus 
of suppuration. 

The symptoms at first are pain, swelling, and tenderness, well localized. 
But the progress may be slow and the general health may not be seriously 
disturbed for a long period. When, however, pus has formed in considerable 
quantity, and is penetrating the structures of the joint, there will usually be 
an accession of the severe symptoms, as fever, loss of flesh, and rigors, fol- 
lowed by perspirations. 

The prognosis will depend upon the stage and progress of the disease. 
In the early period with complete rest of the joint, with a well-applied plas- 
ter-of-Paris dressing extending from the toes to the hip, and with tonic 
treatment, the disease may sometimes be arrested. But there is frequently a 
certain danger of deformity remaining, and a liability to a renewal of the 
disease. If the disease is advanced, perfect results are more likely to be 
secured when the tuberculous tissues are completely removed. In these 
conditions operative procedures, by which the infective material is destroyed 
or removed, offer the best chance of permanent recovery. 

When the knee-joint is filled with fluid, aspiration will relieve the dis- 
tention, and to that extent prove useful. A more radical treatment is the 
injection into the cavity, after its evacuation, of an ethereal solution of iodo- 
form. For this purpose a trocar may be used both to withdraw the fluid and 
to inject the iodoform. Before the iodoform is injected, it is well to wash out 
the cavity with a boric-acid solution. It may be necessary to inject the 
iodoform several times at intervals of a week or more. 

Arthrectomy is a much more useful operation where the synovial mem- 
brane is extensively diseased. It consists in completely exposing the inte- 
rior of the joint, and with the forceps and scissors cutting away all diseased 
tissues. The joint may be exposed by making a flap convex downward or 
convex upward, or by a transverse incision over the centre of the patella, 
and sawing through that bone, but uniting it, after the joint is cleared, by 
wire or even by silk ligatures. Too much care cannot be taken to excise 
every particle of tuberculous structure, and hence the operation, if well per- 
formed, will be tedious. If small cavities in the cartilage and bone are 
filled with tubercle, they should be thoroughly scraped with a sharp 
spoon. 

If the tuberculous cavities are found to involve the articular ends of the 
bones, excision becomes necessary, and may be successfully performed by 
one familiar with operative procedures. The most useful operation is as 
follows : 



DISEASES OF THE JOINTS. 



569 



Fig. 179. 



The leg being slightly flexed on the thigh, make a curved incision, commencing 
at the insertion of the internal lateral ligament into the inner condyle of the femur, 
and passing just below the lower extremity of the 
patella, terminate it at the same point on the external 
aspect of the joint : the lateral incisions should not be 
made lower than the insertion of the lateral ligaments, 
to avoid division of the articular arteries ; remove 
all diseased and degenerated tissues ; reflect flap up- 
ward (Fig. 179) : remove the patella if diseased ; if not, 
leave it undisturbed and divide the lateral and 
interarticular ligaments ; pass a fold of cloth through 
the joint, and draw it firmly under the extremity of 
the bone to be sawn, thus completely isolating the soft 
parts behind : apply the saw first to the extremity of 
the femur, and then to the articular head of the tibia. 
The bones must be maintained in apposition by two 
or three silver wires, which should now be introduced 
into the anterior part of the tibia and femur, and, when 
sufficiently twisted, cut off and the ends turned down 
between the bones. 

The dressings should be antiseptic — viz. layers 
of iodoform gauze next to the wound, then gauze 




bandages treated with bichloride solution, next 



Excision of knee. 



borated cotton firmly bound by gauze bandages, 
and last gypsum bandages sufficient to immobilize the knee. The more 
superficial dressings should extend from the hip to the ankle. The limb 
should now be placed in a sling. The dressings should not be changed, 
except to remove the drain-tube, for several weeks. The wires are allowed 
to remain. 



The Ankle-joint. 

Synovitis of the ankle-joint results from that form of injury known as a 
" sprain." This is due to the sudden turning of the foot when planted on a 
rounded body, as a stone or stick. A strain of the ankle may occur when 
the foot is caught and the child falls, as at play. The pain on attempting to 
walk is more or less severe, and the joint at once swells from the effusion 
which results from the rupture of tissues. 

Owen states that " in this stretching the synovial membrane also participates, 
and a considerable amount, if not of blood, at least of altered synovia, is quickly 
poured into the interior of the joint." 

The important features of the treatment are complete rest and the 
early application of hot water. To carry out this treatment satisfactorily 
the child should first be confined to the bed, with the foot elevated. The 
leg, nearly to the knee, should at once be placed in hot water of a tempera- 
ture as high as can be borne. After a submersion of half an hour the 
ankle should be wrapped with three or four layers of flannel wrung out of 
water as hot as the child will tolerate, and covered with oiled silk to retain 
heat and moisture. These dressings should be renewed every three or four 
hours, or the heat may be maintained by a hot-water bag or hot-water bot- 
tles, especially at night. After this treatment has been continued for one 
day, the dressings should be changed for hot camphorated oil. The swell- 
ing usually rapidly subsides, and then adhesive strips should be applied 
to the entire ankle, and retained two or three weeks or until the cure is 
complete. 



570 



LOCAL DISEASES. 



Fig. 189. 



Gentle but very firm rubbing of the foot, ankle, and leg, with the hand 
softened with vaseline or oil, will be very useful 
in restoring the functions of the joint. The 
child may begin to move about on crutches 
when action gives no pain, but actual attempts 
to walk must be delayed until the joint has 
so far recovered that the weight can be readily 
borne. 

Tubercular disease of the ankle is chronic 
in its character, and, like this affection in other 
joints, is often obscure at its origin. The pain 
is slight, the swelling limited, and the lame- 
ness unnoticed. At length the puffmess about 
the posterior and inner part of the ankle be- 
comes noticeable (Fig. 180), lameness increases, 
and the pain prevents the free use of the foot. 
The disease usually commences in the synovial 
membrane, but it is frequently complicated with 
tuberculous affections of the tarsal bones. As 
the disease progresses the swelling increases, 
until the joint has a peculiar tuberose or 
spindle-shaped appearance. The foot assumes 
a position of extension, unless the tarsus is 
involved, when the whole foot and ankle be- 
come a swollen mass, with the foot at right angles to the leg. The disease 
often extends, also, along the sheaths of tendons, giving rise to swelling in 
the lower part of the leg, the dorsum of the foot, and even the plantar 
region, though the plantar fascia maintains the arch of the foot. 

The treatment, in the early stages, is proper fixation of the joint. This 
is readily and effectually accomplished by the plaster-of-Paris bandage. In 
its first application care must be taken to protect the limb by covering it with 
so much cotton batting that the plaster will not produce irritation of the 
skin. It is especially important to envelop the swollen ankle with a large 
amount of the cotton, in order that the bandages may be applied very tightly 
for the purpose of securing as much pressure as possible. Compression is an 
important feature in the treatment, and the cotton, while protecting the skin, 
has an elasticity which is highly beneficial. When the plaster dressing is 
well applied, the child can move about on crutches, keeping his diseased foot 
from the ground. 

Sayre very properly attaches great importance to extension in the treatment of 

Fig. 181. 




Tubercular disease of the ankle. 




Sayre's steel brace. 



Apparatus applied. 



DISEASES OF THE JOINTS. 



571 



ankle-joint disease, and has devised an ingenious apparatus for that purpose : The 
steel brace is applied (Fig. 1S1) as follows : Cut adhesive plaster in strips about one 
inch in width, and long enough to reach from the ankle to near the tubercle of the 
tibia, and placed all around the limb : secure the plaster in its position, to within 
an inch of its upper extremity, by a well-adjusted roller, as seen in Fig. 181 ; fix 
the instrument and secure the foot firmly by a number of strips of adhesive plaster. 
In applying the gypsum brace the foot, held at a right angle, is wound with 
plaster from the base of the nail of the great toe as far as the disease extends, and 
from above the ankle almost to the knee. The bracket is placed in position and 
bound down by repeated turns of the plastered bandage, taking care that the foot is 
still at right angles ; the whole is neatly covered with fresh bandage. 

If the case progress unfavorably, pus forms and makes its appearance at 
the inner or outer side of the joint. The treatment should now be changed. 
The pus should be evacuated by incision and the joint thoroughly examined. 
If the abscess does not communicate with the joint, the plaster bandage 
should be renewed, and a window should be cut in it over the opening, so as 
to allow the escape of pus and the use of proper dressings. If, however, the 
synovial membrane is pulpy and the cartilage disintegrated, the joints should 
be exposed and all injured tissues removed. Although arthrectomy does not 
usually succeed at the ankle as well as at the knee-joint, it is worthy of trial. 
The method of operating is not unlike that of excision. 

If the disease has also seriously damaged the bone, as well as the soft 
structures of the joint, excision must be performed. The operation is diffi- 
cult, and the results are not always favorable. The chief difficulty encoun- 
tered is the proper exposure of the parts to be removed without injuring im- 
portant structures. It is necessary to avoid dividing the tendons of the mus- 
cles of the legs, as well as the arteries and nerves. Methods of operating, 
therefore, which involve the incision of such structures should not be 
adopted. 

The operation which best preserves vessels, nerves, and tendons, as well 
as the periosteum, is by two longitudinal incisions, one over the external and 
the other over the internal malleolus, and extended above and below suf- 
ficiently to give free access to all of the diseased bone. All transverse in- 
cisions involving the vessels, nerves, and tendons should be avoided. The 
limb being turned on the inner side upon a firm pillow, make an incision two 
or three inches long (B, Fig. 182) on the middle of the fibula down to the 



Fig. 182. 




Excision of ankle ; outer surface (Treves). 

point of the malleolus, and sufficiently deep to divide the periosteum ; from 
the extremity of the malleolus continue the incision backward around the 



572 



LOCAL DISEASES. 



malleolus, an inch, merely through the skin, so as not to injure the tendons, 
and jet permit of their being raised from behind the malleolus ; at the 
point where the bone is to be divided separate the periosteum with the raspa- 

Fig. 183. 




Excision of ankle ; inner surface (Treves). 

torium, and turn down as much as circumstances will permit ; introduce the 
point of the index finger or a spatula into the interosseous space to protect 
the soft parts during the act of sawing ; incline the saw slightly toward the 

joint, so that the part to be removed will be 
external at the point of division ; seizing the 
upper extremity of the fragment with very 
strong forceps, separate its connections with 
the raspatorium and knife when necessary. 
Now turn the foot upon the external surface, 
and make the same straight incision as upon 
the fibula, and a transverse one at its lower end 
(B, Fig. 183) ; the periosteum is more easily separated than from the fibula ; 
saw the tibia in place with a fine-bladed saw. It may be possible, after the 
periosteum has been separated and the ligaments incised, to gradually dislo- 

Fig. 185. 




Fig. 184. 



Suspension-splint. 



J 




Leg suspended. 



cate the foot outward with the aid of the knife, and remove the tibia with 
the saw. To gain more complete access in many cases the incisions made 
along the centre of the malleoli may be extended laterally along the margins 
of the extremities of these bones. Or the same result may be attained by 



DISEASES OF THE JOINTS. 573 

extending the incisions made along the posterior margins of the tibia and 
fibula around the lower and anterior margins of the malleoli (Figs. 182, 183). 
The after-treatment requires the protection of the ankle from movements, 
with free drainage. This is best effected by apparatus which allows suspen- 
sion of the limb. A convenient method of suspending the limb is as follows : 
Make a splint of wood or metal fitted to the anterior surface of the leg and 
ankle (Fig. 184), with rings inserted at three points for suspension ; in its 
application the splint is well padded and laid on the front part of the leg 
and the limb fixed in the ordinary bandage, the ankle being free (Fig. 185) ; 
or the gypsum bandage may be applied over the splint and around the leg, a 
layer of old flannel being first adapted to the leg and the ankle left exposed. 

The Tarsus. 

Synovitis of the tarsal joints occurs when the anterior part of the foot is 
caught and the leg is twisted by the movements of the body. This is a 
i: sprain of the foot."' The injury consists in the tearing of the ligaments 
of these joints and injuries to the synovial membranes. The tarsus swells 
quickly in the line of the injured joints, and is very painful on pressure and 
on moving the anterior portion of the foot. 

The treatment should be the same as that given for similar injuries 
of the ankle-joint — viz. absolute rest, hot water at first, followed by strap- 
ping or the plaster-of-Paris bandage. 

Tubercular disease of the tarsal joints and bones of children is always 
serious as regards the usefulness of the limb. When the tubercular infec- 
tion has once entered these structures, it spreads insidiously, and its progress 
is arrested with difficulty. Not infrequently it extends to the joints of most 
of the tarsal bones, and both bones and joints become involved in the 
destructive inflammation. The ankle-joint is also often invaded by a pri- 
mary tubercular disease of the tarsus. 

The symptoms develop after an injury, and at first consist of pain 
through the central part of the foot in walking, with swelling in the form 
of a puffiness over the tarsus. At this early stage the precise location may 
sometimes be defined with considerable accuracy by holding the heel firmly 
with one hand, while with the other the anterior part of the foot is moved 
in such manner as to compress the tarsal joints, with friction of their surfaces. 

The early treatment should be that of a sprain. But if suppuration 
occurs, a carefully-planned operation should be performed, having for its 
object the evacuation of pus and the removal of dead structures. Great 
care must be taken to avoid injuring tissues not affected, for the joints of the 
tarsus are so related that one may be curetted without injuring another. No 
special method of operation can be given, but, as a rule, it is important not 
to make a deep transverse incision which will divide the tendons of the 
muscles causing dorsal flexion of the foot. If any one of the dorsal bones 
is carious, it should be carefully dissected from its fellows, the cavity 
thoroughly cleansed and drained, and the foot supported in a plaster-of-Paris 
bandage, with openings that will allow the change of dressings. 

If the disease invade the tarsus so generally that partial excision would 
be satisfactory, the tarsal bones, excepting the calcaneum and astragalus, 
may be removed, and a fairly useful extremity may result. In this case the 
incision may be across the foot, dividing all the tissues down to the bone, for 
dorsal flexion of the foot will not be an important function. When tendons 
are thus divided, they should be reunited by sutures. The support of the 
foot can best be secured by a pasteboard splint applied to the posterior part 
of the leg and to the plantar surface. 



574 



LOCAL DISEASES. 



If the disease still progress, a Syme's amputation at the ankle-joint must 
be the operation of final resort. Excisions of the ankle for tubercular disease 
do not always progress favorably. The infection will sometimes escape the 
most thorough search, or there may be a renewed infection from foci pre- 
existing in the system. There is also in these cases a constant liability to 
infection with pyogenic microbes, owing to the susceptible tissues of stru- 
mous children. If suppuration continue freely, renewed efforts should be 
made to remove sources of septic matters. If, however, the disease continues 
to progress, it may finally be necessary to resort to amputation at the joint. 

The method of amputation which gives the most favorable results, both 
in the prompt recovery of the patient and in the adaptation of a stump for 
an artificial limb, is Syme's. PirogofTs method, which some recommend, has 
two disadvantages — viz., first, the fragment of bone taken from the os calcis 
is liable to necrose, owing to the failure of nutrition ; and, second, the stump 
is not as well adapted to an artificial foot, owing to the length of the limb, 
which brings the ankle-joint too near the surface for easy progression. 

Syme's amputation is as follows : Place the foot at a right angle to the 
leg ; enter the knife at the point of the external malleolus (B, Fig. 182), and 
carry it directly across the sole of the foot to a point opposite, or six lines 
below the internal malleolus (B, Fig. 183) ; the posterior tibial artery divides 
beneath the internal annular ligament into the internal and external plantar 
arteries, and if the incision extends to the point of the internal malleolus, the 



Fig. 186. 



Fig. 187. 





Syme's amputation of the foot : anterior 
incision and disarticulation. 



Syme's amputation of the foot : 
cleaning the os calcis. 



vessel may be divided ; join the two extremities of this incision by an anterior 
incision in a direct line over the instep, so that the cicatrix may come well in 
front (Fig. 186). In dissecting the posterior flap, place the fingers of the 



DISEASES OF THE JOINTS. 575 

left hand upon the heel, and with the thumb press the edge of the flap 
firmly backward, cutting between the nail of the thumb and the tuberosity 
of the os calcis (Fig. 1ST), so as to avoid lacerating the soft parts ; the tendo 
Achillis is exposed and divided. Disarticulate the foot and saw off the 
malleoli, leave the articular extremity of the tibia uninjured, for it is better 
not to interfere with the bone if it is healthy. 

The Foot. 

In cases of disease or injuries which so involve the anterior part of the 
foot as to render amputation necessary, it is important to save the phalanges 
as far as possible. Of these it must be remembered that the great toe is the 
most useful in the act of walking. The spring and elasticity of the step of 
the patient depends more on this toe than on all the others taken together. 
This toe should not, therefore, be sacrificed if it is possible to preserve even 
a portion of the phalanx. While the other toes are comparatively less use- 
ful in the preservation of a good step, they are important in maintaining the 
proper breadth of foot. 

In amputating one or more phalanges the flap should be so constructed 
as to bring the plantar surface over the stump, so that this dense tissue will 
receive the pressure of the shoe, and the impact of the step when the foot 
strikes the ground. This operation requires a short dorsal and a long plantar 
flap, so formed that the cicatrix is on the dorsal surface rather than on the 
end of the stump. 



SECTION II. 
DISEASES OF THE CEREBROSPINAL SYSTEM. 



Diseases of the brain and spinal cord are less frequent than those of the 
respiratory and digestive systems, and, being less amenable to treatment, they 
largely increase the aggregate of deaths. They contrast with the diseases of 
the other systems in their greater relative frequency in infancy and childhood 
than in adult life. This is explained, as regards the brain, by the rapid devel- 
opment and active molecular change in this organ in early life, its great im- 
pressibility by the emotions, and the thinness of the covering which protects 
it from external agencies. 

Some of the most important of the diseases of the cerebro-spinal system 
are peculiar to early life, as tetanus infantum and spina bifida. The diseases 
of this system also contrast with other local affections in their greater obscur- 
ity, especially in their commencement ; for, while maladies of the thorax can 
be readily ascertained by auscultation and percussion, or those of the abdo- 
men by the nature of the evacuations or the degree of tenderness or disten- 
tion, our means of conducting examination through the bony encasement of the 
cerebro-spinal axis are meagre and unsatisfactory. The condition of the brain 
and spinal cord must be determined chiefly by the study of symptoms, and 
not by direct examination. The state of the anterior fontanelle in young in- 
fants, however, enables us to determine the presence or absence of active con- 
gestion of the brain. If there be an excess of arterial blood, it is convex. 
Prominence of the fontanelle is common in inflammatory and febrile diseases, 
and is a sign of considerable diagnostic and prognostic value. 

Within a few years the ophthalmoscope has been employed as a means of 
diagnosis in cerebral diseases, and, although the use of this instrument for 
such purposes is but recent, enough has been elicited to prove its value as 
an aid in determining the state of the brain. Prof. H. D. Noyes remarks on 
this subject: ". . . . The argument for making ophthalmoscopic examination 
in all cases of brain disease becomes irresistible. Indeed, a moment's reflec- 
tion would lead to this conclusion without any considerations drawn from 
pathology. The optic nerve is only an outlying portion of the brain ; its 
extremity is fully exposed to view. Situated within about two inches of the 
brain, it is the only nerve in the body which we can inspect ; it contains blood- 
vessels which communicate directly with the intracranial circulation. We 
thus come into relation with the cerebrum by continuity of nerve-structure 
and also of blood-vessels." 

Structural changes in the optic nerve and retina have been discovered by 
means of the ophthalmoscope in meningitis, hydrocephalus, phlebitis of the 
sinuses, apoplexy, etc. Among the lesions which have been observed by this 
instrument are hyperemia, more or less opacity and tumefaction of the optic 
nerve, engorgement of the vessels of the retina, with serous or sero-fibrinous 
exudation and ecchymotic points. In certain protracted diseases, as chronic 
hydrocephalus, in which dimness or loss of sight occurs, the ophthalmoscope 
discloses a state of atrophy of the optic nerve. Heretofore this instrument 
has been chiefly employed by oculists, but as it comes into more general use 



DISEASES OF THE CEREBROSPINAL SYSTEM. 577 

there can be little doubt that it will be recognized as an important aid in the 
diagnosis of obscure cerebral diseases. 

Still, with all possible aid to diagnosis, the obscurity which attends the 
invasion of many of the cerebro-spinal diseases must be acknowledged. To 
the hasty and careless physician their symptoms are often deceptive. Careful 
weighing of the phenomena and thorough and protracted examination are 
requisite in order to ensure correct diagnosis and proper treatment. Some 
of the cerebro-spinal affections are, in reality, sequelae of other diseases — as, 
for example, spurious hydrocephalus — and some are, strictly speaking, only 
symptoms, as convulsions ; but on account of their importance, and because 
they require special treatment, it is proper to consider them as diseases per se. 

The brain presents certain peculiarities in infancy and childhood. In the 
foetus, while the other organs are well formed, the brain, especially its cerebral 
portion, is still diffluent, and at birth it has so little consistence that it must 
be handled carefully to prevent laceration. This softness is due to the large 
proportion of water which it contains. The following analyses show the com- 
position of the brain in three periods of life : 

Infant. Youth. Adult. 

Albumen 7.00 10.20 9.40 

Cerebral fats 3.45 5.30 6.10 

Phosphorus 0.80 1.65 1.80 

Osmazome, salts 5.96 8.59 10.19 

Water 82.79 74.26 72.51 



At birth the brain has a nearly uniform white color. The gray substance, 
in which the nervous power originates, is undeveloped. The date of its ap- 
pearance corresponds with the first exhibition of emotion or intelligence, and 
the decided gray color which we observe in the brain of the adult does not 
appear until the age of full mental activity. 

In the new-born the brain is large in proportion to the rest of the body, 
and its growth during infancy and childhood is rapid. Until the fifth year, 
as appears from the observations of Dr. Peacock, its weight is about one- 
seventh or one-eighth that of the entire system, the proportion varying some- 
what in different cases. 

The brain does not attain its full size, as stated by Dr. West, at the age of 
seven years, but, according to Dr. Peacock's statistics, it continues to increase 
till the age of twenty-five or thirty, although its growth is less rapid after the 
age of seven years than previously. 

The membranous covering of the cerebro-spinal axis is scarcely less inter- 
esting to the pathologist than the axis itself. I shall speak in the follow- 
ing pages of the arachnoid and cavity of the arachnoid for convenience of 
description, although aware of the fact that some eminent authorities, as 
Virchow and Kolliker, whose opinions in reference to the minute anatomy 
of the system always command attention, if not assent, believe that there 
is no arachnoid, but what has heretofore been called by this name is on the 
one side the smooth surface of the dura mater and on the other of the pia 
mater. 

The dura mater is seldom involved in the diseases of early life, except as 
it is affected by pressure, while the pia mater and arachnoid are the seat and 
source of some of the most important diseases, as meningitis, meningeal 
apoplexy, etc. 

The more complicated and delicate the structure of an organ, the more 
liable it is to errors of nutrition and growth. There is, therefore, no organ 
which is so liable to irregular development as the brain. It may be entirely 
wanting or it may be partially developed, certain portions being absent, or, 
lastly, its growth may be excessive, constituting hypertrophy. 
37 



578 LOCAL DISEASES. 

CHAPTER I. 

CONGESTION OF THE BRAIN. 

Congestion of the brain is not peculiar to infancy and childhood, but it is 
much more common in these periods of life than subsequently. This is due, 
in a great measure, to the fact that in the young the circulation is more 
readily disturbed by moral as well as physical causes than in the adult. 

Congestion of the brain is occasionally primary ; more frequently it occurs 
as a concomitant or sequel of some other affection. Diseases, whether con- 
stitutional or local, which in the adult have no appreciable effect on the vas- 
cularity of the brain often cause in the child a decided increase of blood in 
this organ. 

Causes. — Cerebral congestion is of two kinds, active and passive. The 
former results from a cause which directly affects the brain and increases the 
flow of blood toward it, or from a cause operating primarily on the heart and 
increasing the frequency and force of its systolic movement ; the latter is 
due to some obstruction in the course of the circulation or to feeble propel- 
ling power on the part of the heart. 

Among the causes which most frequently produce active congestion of 
the brain in the child may be mentioned blows or falls on the head, excessive 
fatigue or excitement, heat, dentition, and also various inflammatory and 
febrile affections, especially in their first stages. 

Cerebral symptoms occurring in the course of an essential fever are no 
doubt often due, in a great measure, to the irritating effect on the brain of 
the specific principle, whatever it may be, circulating in the blood. Occur- 
ring in inflammatory diseases which are located elsewhere than within the 
cranium, they are often attributed to functional disturbance of the brain. 
But observations show that symptoms referable to the brain, arising in the 
commencement of the essential fevers and of the phlegmasia, are in many 
instances preceded by, and are therefore doubtless in greater or less degree 
dependent on, hypersemia of this organ. 

Difficult as it is to ascertain the state of the brain in many diseases in 
which it is involved, we may determine whether or not there be congestion 
in the young child by observing the anterior fontanelle. If it be elevated and 
tense in an acute disease, hyperemia is indicated. Now, it is often unusu- 
ally prominent in fevers and inflammations, especially in their first stages. 
when cerebral symptoms are present. Its elevation, under such circum- 
stances, is obviously coincident with cerebral congestion. 

The acute inflammations which are most likely to be attended by cerebral 
congestion are those of the mucous surfaces and pneumonia. Severe coryza, 
tracheo-bronchitis, entero-colitis, and colitis, commencing suddenly with great 
febrile excitement, are frequently accompanied in their initial stage by active 
congestion of the cerebral vessels. Cases like the following, which I find in 
my note-book, are not infrequent : 

An infant, four months old, had been sick about two days with coryza and 
bronchitis when I was called to see it; the pulse numbered 156, respiration 64; it 
took the breast, but was restless : cough frequent and dry : bowels moderately relaxed. 
The mucous membrane of the fauces was injected, and coarse mucous rales were 
present in the chest. The anterior fontanelle rose above the level of the cranium 
and pulsated forcibly. Soon after convulsions occurred, which were relieved by 
appropriate measures, and on the following day the fontanelle had subsided. The 
patient gradually recovered without any untoward symptom. 



CONGESTION OF THE BRAIN. 579 

Cerebral congestion and convulsions often mark the initial stage of active 
intestinal phlegmasia. This is especially true of dysentery. The little 
patient, perhaps from the very inception of the colitis, is drowsy ; its surface 
is hot ; pulse full and rapid. There is sudden and momentary starting or 
twitching of the limbs. The anterior fontanelle, if still open, is elevated, 
and it is not till the lapse of several hours that the cause of these symptoms 
is apparent from the occurrence of bloody stools. 

The causes of passive congestion of the brain are very different from 
those of the active form. A common cause is obstruction in a sinus or vein 
by a fibrinous concretion or by a tumor or abscess external to it. 

I have occasionally met cases in which this form of cerebral congestion 
appeared to be plainly referable to obstruction to the return of blood from 
the brain by the pressure of bronchial glands, enlarged by hyperplasia in 
tubercular disease, these bodies diminishing by external pressure the calibre 
of the venge innominatae or the descending vena cava. Rilliet and Barthez 
have called attention to such cases in the clinical history of tuberculosis. 
The following case may be cited as an example ; it occurred in the infants' 
service of the New York Charity Hospital : 

An infant, about one year old, affected with tuberculosis, both bronchial 
and pulmonary, was observed during the ten days preceding its death to bore 
the pillow with its head almost constantly, so as to wear the hair from the 
occiput. The movement of the head was the only prominent cerebral symp- 
tom. Nothing abnormal was noticed in the appearance of the eyes, nor was 
the stomach irritable. A spasmodic cough and progressive emaciation 
attracted attention, but these were referable to the tubercular disease. At 
the autopsy we found the cerebral sinuses, veins, and capillaries greatly con- 
gested. On tracing the veins which return blood from the brain, an inflamed 
and enlarged bronchial gland was discovered in the angle formed by the con- 
vergence of the right and left venas innominatae. This gland, which con- 
tained but a single point of cheesy degeneration, had attained such a volume 
by proliferation of its cells that it pressed upon both vessels, so that it had 
obviously retarded the circulation in each and given rise to cerebral conges- 
tion of the passive form. 

Passive congestion often occurs in the infant at birth, either from tedious- 
ness of the labor or delay in the expulsion of the body after the birth of the 
head. If it be simple congestion, and not congestion with hemorrhage, it 
soon passes off. Passive congestion of the brain also occurs in severe parox- 
ysms of whooping cough, in which return of blood from this organ is tem- 
porarily retarded. All are familiar with the congestion which occurs in 
parts external to the cranium from the severity of the cough, producing 
epistaxis, extravasations under the conjunctiva, etc. The extracranial con- 
gestion obviously indicates the presence and degree of congestion within the 
cranium. 

Those who practise in malarious regions sometimes meet cases of danger- 
ous passive congestion of the brain, the result of malaria, occurring especially 
in the cold state of intermittent fever. In these cases the surface is pallid, 
its temperature reduced, and the pulse feeble. The blood, leaving the pe- 
ripheral vessels, collects in undue quantity in the internal organs, producing 
congestion of the brain as well as of the thoracic and abdominal viscera. In 
the child with malarial disease, in whom there is less vigor of constitution 
than in the adult, death sometimes results from this passive congestion. Two 
such cases have occurred in my practice, although in this latitude the malarial 
maladies are mild in comparison with the type which they present in many 
parts of the United States. 

Symptoms. — The symptoms of active congestion of the brain are stupor, 



580 LOCAL DISEASES. 

heat of head and headache, throbbing of carotids, restlessness when aroused, 
twitching of the limbs, and perhaps convulsions. There is also sometimes 
intolerance of light, and the anterior fontanelle. if open, pulsates strongly. In 
passive congestion many of the symptoms are the same as in the active form. 
Stupor, twitching of the limbs, and fretfulness or irritability when the patient 
is disturbed are common, ordinarily without increase of temperature : the 
surface may indeed be cool, and the face is not flushed nor the eyes injected. 
The strong pulsation and elevation of the anterior fontanelle, so conspicuous 
in active congestion, are — the former always, the latter often — lacking. 
In both acute and passive cerebral congestion, constipation is a common 
symptom. 

In many cases the symptoms of congestion of the brain are associated 
with others which proceed directly from the cause of the congestion, but it is 
not difficult, unless in exceptional instances, to determine which are due to 
the congestion and which to the antecedent and coexisting pathological state. 

Anatomical Characters. — In active congestion there is an excess of 
arterial blood in the brain and its membranes. The arteries, to their minutest 
branches, are seen to be full, presenting the bright hue of oxygenated blood. 
In passive congestion the sinuses and veins are distended. The pia mater. 
choroid plexus, and the vessels of the brain have a darker appearance than in 
active congestion. In both forms of congestion, unless they quickly abate, 
other anatomical changes soon occur. If there be great distention of the 
capillaries, these vessels are liable to give way. and we find here and there 
little patches of extravasated blood. In other cases the over-distention is 
relieved by the transudation of the serous portion of the blood through the 
coats of the vessels. The cephalo-raehiclian fluid is then found in excess 
external to the brain and in the ventricles. 

Prognosis. — The duration and the result of congestion of the brain 
depend, in great measure, on the nature of the cause. If the cause be 
trivial, as mental excitement, fatigue, exposure to heat, there is usually 
prompt relief if the condition of the patient be understood and properly 
treated. If the cause be general or constitutional, as one of the essential 
fevers or whooping cough, or if it be local, but its seat external to the 
cranium, the prognosis, so far as the congestion is concerned, is not unfavor- 
able if there be a timely and judicious use of remedies. The most unfavor- 
able cases are those in which the cause is seated in the encephalon and those 
in which there is some obstructive disease in the course of the circulation. 
Congestion occurring from a structural change within the cranium is. from 
the nature of the cause, without remedy and ordinarily fatal. Obstructive 
diseases of the circulatory system, wherever located, being for the most part 
permanent, give rise, as a rule, to incurable congestion. 

Congestion of the brain, if it be not relieved in a few hours, becomes 
less and less amenable to treatment. It soon passes beyond the resources of 
our art and ends in coma : it is seldom protracted beyond a few days. Extrav- 
asations of blood, common in active congestion, and serous effusion, common 
in the passive form, diminish the chances of a favorable result. 

Treatment. — The indication for treatment in active congestion is plain. 
Measures should be employed which produce derivation from the brain. 
Unless there be an asthenic primary affection, in the course of which the 
congestion is developed, active purgation is required. A saline purgative is 
ordinarily preferable. If the stomach be irritable, there is no better purga- 
tive than calomel. In all cases of active congestion, whatever the cause, 
the bowels should be kept open. It is often better not to wait for the tardy 
action of a cathartic, but to give at once an enema of soap and water or salt 
and water. External derivative agents are also indicated. A warm mustard 



INTRACRANIAL HEMORRHAGE. 581 

foot-bath, sinapisms to the back of the neck or chest and to the feet, and 
cold applications to the head, are measures which should never be neglected. 
In many cases those medicines are useful which reduce the contractile power 
of the heart, as phenacetin. 

This treatment, if employed early, will relieve the congestion in a large 
proportion of cases ; but if there be no improvement and if the child be 
robust, an ice-cap should be constantly applied to the head. If after the 
lapse of some hours cerebral symptoms continue, sanguineous or serous effu- 
sion has probably occurred. 

The treatment appropriate for passive congestion is somewhat different : 
cold applications to the head and those of a derivative nature to the extremi- 
ties are useful. As this form of the disease is not primary, but is dependent 
on some antecedent pathological state, it is evident that it can only be treated 
successfully by removing or obviating the cause as far as possible. But the 
nature of the various obstructions to the intracranial circulation is such that 
our ability to accomplish this end is very limited. 

If the cause be constitutional, or if it be some disease in the neck or 
chest, it may sometimes be partially or even wholly removed, but if seated 
within the cranium it is beyond our control. In general, it may be said that 
depletion is not required or tolerated in passive congestion, and stimulants 
are often needed. 



CHAPTER II. 

INTEACEANIAL HEMORRHAGE (MENINGEAL HEMOEEHAGE, 
CEEEBEAL HEMOEEHAGE). 

Hemorrhage within the cranium is not very infrequent in infancy and 
childhood, and there is no part of the encephalon, whether the meninges or 
brain, in which it does not sometimes occur. If the blood be extravasated 
upon the surface of the brain or between the meninges, the disease is des- 
ignated by writers meningeal apoplexy ; if in the substance of the brain, 
cerebral apoplexy. Extravasation may also occur in one of the lateral 
ventricles. 

Causes. — Apoplexy is usually (there is an exception) preceded by con- 
gestion. If the congestion increase to a certain degree, the distended capil- 
laries give way and extravasation of blood results. Therefore the causes of 
congestion which have been enumerated in the preceding chapter are, in great 
measure, those of apoplexy. Microscopic examinations have demonstrated 
that the corpuscular elements of the blood may escape from capillaries with- 
out rupture. While, therefore, it is probable that intracranial hemorrhage in 
early life commonly occurs from rupture, its occasional occurrence by 
diapedesis, or escape of blood through the walls of the capillaries, must be 
admitted. 

Intracranial hemorrhage is not infrequent in the new-born. It results in 
them from tediousness of the birth and severity of the labor-pains. At first 
there is extreme congestion of the meningeal and cerebral vessels, correspond- 
ing with that of the scalp and face. This congestion, continuing, soon ends 
in extravasation of blood. In some of these cases forceps have been used to 
effect the delivery, but it is doubtful whether the use of instruments mate- 
rially increases the congestion or the amount of extravasation. Certainly, in 
a large proportion of intracranial as well as supracranial hemorrhages of the 



582 LOCAL DISEASES. 

new-born, instruments have not been used. An additional cause of the hem- 
orrhage is, in some instances, the use of ergot, which, by producing strong 
and continuous labor-pains, interrupts the placental circulation and increases 
the congestion of the foetal veins and capillaries. 

In infants a few days old intracranial hemorrhage may result from that 
rapid and fatal disease, tetanus infantum. The hemorrhage is preceded by 
intense passive congestion, which the tetanic rigidity and spasms produce by 
obstructing respiration and circulation. Few cases of tetanus infantum occur 
without more or less extravasation of blood, either meningeal or cerebral. 
Another cause of this disease is obstruction in the vessels which return the 
blood from the brain. The various structural changes which produce this 
obstruction in different cases have been sufficiently described in our remarks 
on cerebral congestion. 

The congestion which precedes hemorrhage, when occurring under the 
conditions described above, is passive. 

Among the causes which produce hemorrhage through the intermediate 
state of active congestion may be mentioned great mental excitement, of 
which M. Legendre relates a case, and lengthened exposure to the sun's rays, 
an example of which Eilliet and Barthez have seen. It is also said that 
compression of the aorta by an enlarged liver or an abdominal tumor has 
sometimes produced meningeal or cerebral hemorrhage by causing an increased 
afflux of blood to the head. A very important cause of cerebral or menin- 
geal hemorrhage to which I have not alluded is that general state of the 
circulatory system which is designated by the term purpura hemorrhagica. 
This sometimes results from the antihygienic conditions in which the child is 
placed. In other instances it results from some antecedent disease, pro- 
tracted and debilitating, which has produced a profound alteration in the 
state of the blood and the vessels. The capillaries become less firm and 
elastic and easily give way, so that in such patients ecchymotic points are 
ordinarily found in different parts of the system. The diseases which occa- 
sionally end in this hemorrhagic diathesis are numerous. I have known it to 
occur after measles, scarlet fever, and smallpox. It is also an occasional 
sequel of chronic diarrhoea or intermittent and typhoid fevers, and of 
rachitis. 

Anatomical Characters. — Hemorrhage in or upon the brain in infancy 
and childhood differs in important particulars from that occurring in adult 
life. In the adult, and more so as life advances, the arteries become less 
distensible and more brittle, so that when hemorrhage occurs it is usually 
from one of these vessels. In early life, on the other hand, the blood does 
not ordinarily escape from an artery, but, as has been stated, from the capil- 
laries. The extravasation is not, therefore, so rapid and violent, and is not 
attended by such laceration and injury of surrounding parts in infancy and 
childhood as at a subsequent age. In the adult the hemorrhage commonly 
occurs in the substance of the brain. The flow of blood from the ruptured 
artery separates the brain-substance, producing a cavity in which a clot 
forms. This constitutes the usual form of apoplexy in the adult. In the first 
years of life, on the contrary, the extravasation is commonly from the 
meninges, and the symptoms to which the effused fluid gives rise are for the 
most part due to its mechanical effect. Cases of hemorrhage in the sub- 
stance of the brain constitute a small minority, unless during the days imme- 
diately succeeding birth. In early life, therefore, on account of its greater 
frequency, meningeal hemorrhage is a disease of more importance than cere- 
bral, and its anatomical character should be carefully studied. 

In meningeal hemorrhage the extravasation may be between the cra- 
nium and dura mater, upon the visceral layer of the arachnoid, in the meshes 



INTRACRANIAL HEMORRHAGE. 583 

of the pia mater, or in a lateral ventricle from rupture of the capillaries in 
the choroid plexus. Much the most common seat is external to the pia 
mater in the so-called cavity of the arachnoid ; the blood escaping in this 
situation spreads uniformly in all directions. It soon separates into two por- 
tions, the solid and liquid. The solid portion, or the clot, is free or but 
slightly attached to the adjacent membrane. The meninges in the vicinity 
of the extravasated blood preserve their normal appearance or are but slightly 
injected; the clot gradually becomes extended on all sides, so as to form a 
lamina at the seat of the extravasation, thinner at its circumference than 
centre, and at first of a dark -red color. The color gradually fades, and the 
lamina, becoming smooth and polished and at the same time more and more 
attenuated, finally resembles the arachnoid in appearance. Its diameter 
varies in different cases from a few lines to two or three or more inches. 
M. Tonnele relates two observations in which the adventitious membrane 
extended over the superior surface of both hemispheres, and in one of them 
also over the falx cerebri. 

The extravasation may occur at any part of the surface of the brain, but 
its usual seat is the vertex. The next most frequent locality is the base of 
the brain. The subsequent history of the delicate membrane into which the 
clot is gradually transformed is interesting. It often extends so as to cover 
more space than was occupied by the extravasated blood, and its edges are 
then scarcely distinguishable, in consequence of their extreme tenuity and 
their close resemblance to the arachnoid. The attachments of this mem- 
brane, so far as it forms any, are usually to the parietal surface of the arach- 
noid. Sometimes a portion of the membrane is attached, while the rest lies 
free, bathed on either side by the liquid portion of the blood which still 
remains from the extravasation. According to M. Legendre, in the most 
favorable cases the serum is absorbed, and the membrane which has resulted 
from the clot, and which I have described, becomes intimately adherent to 
the internal surface of the dura mater. It forms an integral part of this 
membrane, and there only remain a little thickening and increased opacity, 
indicating the seat of the extravasation. The health is fully re-established. 

But the result in other cases is as follows : The serum is not absorbed, 
and the newly-formed membrane, uniting at points with the inner surface of 
the dura mater or its arachnoidal covering, encloses the fluid so as to produce 
a circumscribed hydrocephalus. 

Sometimes there is only one cyst ; in other instances the membrane, 
especially if large, unites in such a way as to give rise to more cysts than 
one. The size of the cyst varies according to the quantity of fluid, which 
may be only a few drachms or several ounces. Rilliet and Barthez report a 
case in which there was a pint of fluid lying over each hemisphere, there 
being two cysts. If the cranial bones are not united, so that they yield to 
the pressure, the size of the cranium is increased, and if the extravasation 
be confined to one side, an inequality results and the symmetry of the head 
is destroyed. The fluid which causes the enlargement of the head in such 
cases is in part the serum of the extravasated blood and in part a subsequent 
secretion. 

Various writers relate cases of ventricular hemorrhage. Valleix met it 
in an infant that died at the age of two days. In the Edinburgh Journal 
of Medicine and Surgery, October, 1831, an interesting case is related. A 
boy, nine years old, died of hemorrhage in both ventricles, and also at the 
base of the brain and in the spinal canal. In the Nursery and Child's Hos- 
pital of this city the post-mortem examination was made of an infant who 
died at the age of one month. In the posterior cornu of the left lateral 
ventricle were two clots, elongated and black, one larger than the other. In 



584 LOCAL DISEASES. 

the corresponding cornu on the opposite side was a smaller clot. A similar 
post-mortem appearance was observed at the autopsy of a young infant that 
died in Charity Hospital. A dark crescentic clot lay in each posterior cornu. 
The clot, if remaining a long time, undergoes degeneration. In the case of 
an adult in which a year had elapsed after the extravasation I found it to 
contain crystals of cholesterin and carbonate of lime. 

Cerebral hemorrhage, or hemorrhage in the substance of the brain, may 
occur at any time in infancy and childhood. The blood is sometimes extrav- 
asated in points here and there over the entire organ or a part of the organ ; 
in other cases it is extravasated in one or perhaps two cavities, as in the ordi- 
nary form of apoplexy in the adult. In the first form of cerebral hemorrhage, 
or that in which the blood escapes from numerous points through the brain, 
there is evidently little laceration or injury of the organ. The brain-sub- 
stance surrounding the hemorrhagic points sometimes preserves the usual 
appearance. It is white and firm. In other cases it presents a reddish or 
yellowish appearance, and is softened to the depth of a line or two. If the 
hemorrhage occur in a cavity, as in apoplexy of adults, the nerve-fibres are 
evidently torn and separated and there is more or less compression of the 
surrounding brain-substance. Unless the disease be of long standing, the 
cavity contains a dark and soft clot bathed with serum which has a reddish 
or a yellowish-red appearance. The brain in the immediate vicinity of the 
cavity is sometimes softened. Rilliet and Barthez state that they have seen 
8 cases of cerebral hemorrhage of the capillary form ; 10 cases in which the 
hemorrhage was in cavities ; and in 2 of the 18 both forms were present. In 
5 of those in which the form was capillary the disease was limited to portions 
of the brain, while in the remaining 3 the hemorrhagic points were found in 
nearly every part of the brain. 

Apoplectic cavities are seldom seen in the cerebellum, and, whether the 
hemorrhage be capillary or in a cavity, there is in most cases, as previously 
stated, more or less congestion of the vessels of the brain. 

The proportion of cases of cerebral to other forms of hemorrhage is be- 
lieved by some to be greater in the new-born than at any other period of life. 
Valleix relates 4 cases of intracranial hemorrhage occurring at this age, 2 of 
which were cerebral, 1 ventricular, and in the other the extravasation was in 
the cavity of the arachnoid. Mignot has published 8 cases occurring in the 
new-born, in 2 of which the hemorrhage was in cavities in the cerebrum ; in 
3, in the lateral ventricles ; and in 3, external to the brain. If the same 
proportion be observed in other statistics, 1 in 3 of the cases of intracranial 
hemorrhage occurring in the new-born is cerebral. 

Symptoms. — The symptoms in intracranial hemorrhage are not uniform ; 
they vary according to the seat as well as the quantity of the effused blood. 
In some cases the extravasation occurs without such symptoms as would 
direct attention to the brain. When the hemorrhage occurs at the time of 
birth in consequence of strong and long-continued labor-pains, the infant is 
often born apparently dead. This is due partly to the hemorrhage, partly to 
the great congestion of the brain which precedes and accompanies the hemor- 
rhage. Resuscitation is gradual and difficult. The infant's features are livid 
and perhaps swollen ; its respiration is gasping, and both pulse and respira- 
tion are slow. Its cry is feeble, with but slight movement of the facial mus- 
cles, and the lungs are but partially inflated ; the eyelids are closed and the 
limbs almost motionless. By artificial respiration and by friction the pulse 
and breathing may be rendered more frequent, but the latter remains irreg- 
ular and gasping. Finally, the limbs grow cold, the surface, from a state of 
lividity, becomes pallid, and death occurs in profound coma. M. Cruveilhier 
made many observations at the Maternite in reference to the death of new- 



IXTBACBAXIAL HEMORRHAGE. 585 

born infants, and he believes that one-third of those who die in birth at the 
full period die of apoplexy. I have made post-mortem examinations in a few 
cases when death had occurred from this cause, and in all the hemorrhage 
was meningeal. One of these was born on the 30th of December, 1864. The 
birth was delayed by unusual projection of the promontory of the sacrum, 
so that finally the application of forceps was necessary. The infant was ap- 
parently stillborn, but by persistent efforts on the part of the physician who 
assisted it was resuscitated so as to live several hours, though with constant 
embarrassment of respiration and with lividity. At the autopsy a large ex- 
travasation of blood was found in the cavity of the arachnoid over a consid- 
erable part of the convexity of the brain, and the substance of the brain was 
deeply congested. 

Apoplexy in the new-born does not always terminate fatally, or, when 
fatal, in the sudden manner which I have described. Valleix relates the 
case of an infant who died of pneumonia at the age of three and a half 
months. Its birth had been protracted and difficult, but was completed with- 
out the use of instruments. It had had during its entire life paralysis of the 
right side. At the autopsy a clot was found near the base of the right thal- 
amus opticus, evidently existing from birth. Around the clot the brain was 
softened to the depth of some lines and was of a bluish-red color. A very 
similar case is related by M. Vernois. An infant lived forty-nine days with 
paralysis of the left side, and died of pneumonia. At the autopsy a hemor- 
rhagic excavation in process of cicatrization was found behind the right 
corpus striatum and the thalamus opticus. 

Intracranial hemorrhage occurring from accidents of birth is generally 
attended by marked symptoms, such as have been described. But when it 
occurs subsequently to birth, whether in infancy or childhood, the symptoms 
vary greatly in different cases and are generally obscure. I will briefly state 
the symptoms which have been observed in both the cerebral and meningeal 
forms of this disease. First, the cerebral. Sedillot relates the case of a child 
seven and a half years old whose bare head had been exposed several hours 
to the sun's rays. Suddenly, after a paroxysm of anger, it was seized with 
great pain, corresponding with the posterior and inferior fossae of the cranium. 
It uttered piercing cries and died in a quarter of an hour. A clot was found 
in the right lobe of the cerebellum. Richard Quinn (Rilliet and Barthez) 
gives the history of a boy, nine years old, who in playing with a hoop sud- 
denly stopped, carried his hands to his head, and fell backward unconscious. 
Three or four hours afterward, when examined, he was found pallid, surface 
cool, respiration slow and at times stertorous, pulse 50 to 60 per minute ; 
the left arm was flexed, the left leg paralyzed ; the right leg and arm con- 
vulsed ; right pupil strongly dilated, the left contracted. He died seven 
hours after the commencement of the attack, and a large clot was found in 
the centrum ovale on the right side. 

Rilliet and Barthez relate the following case from Campbell : A boy with 
good previous health was suddenly seized about 7 A. M. with repeated vomiting, 
followed in an hour and a half by violent convulsions ; he rolled his eyes and 
uttered inarticulate cries ; pulse frequent and hard ; pupils contracted ; trunk 
and lower extremities cool. In the afternoon he presented symptoms of com- 
pression of the brain, such as dilatation of the pupils, frequent and feeble 
pulse. Death occurred in the evening, and a hemorrhagic cavity was found 
occupying the right middle lobe of the cerebrum. Guibert relates a case of 
extravasation in the superior part of the right hemisphere of the brain in a boy 
fourteen years old. The principal symptoms were feebleness of the limbs, 
inability to walk, cephalalgia, involuntary evacuations, fever, grinding the 
teeth, rigors severe and prolonged, lividity, loss of intellectual faculties, dila- 



586 LOCAL DISEASES. 

tation of the pupils, insensibility to light, stertorous respiration. Death oc- 
curred in about an hour. 

Rilliet and Barthez narrate the history of a girl two years old who, after 
an attack of measles, was taken with convulsions accompanied with fever and 
prostration. The convulsive movements affected especially the eyes and upper 
extremities ; the right leg was immovable ; the left pupil dilated. These 
symptoms resulted from hemorrhage in the corpus striatum and opticus thal- 
amus. The same authors relate also the case of a girl seven years old who 
died with a large apoplectic cavity in the left thalamus opticus. The symp- 
toms were headache, convulsive movements, loss of consciousness, delirium, 
vomiting, constipation, and convergent strabismus. The symptoms nearly dis- 
appeared, but in a few days the headache returned, with strabismus and a 
slight drawing of the face toward the left ; on the twenty-seventh day con- 
vulsive movements of the right eye were observed, with paralysis of the arm. 
Finally, contraction of the arms occurred, with acceleration of pulse, irregular 
breathing, dilated pupils, paralysis, and retraction of the head, followed by 
death on the forty-eighth day. 

These cases, and those from Valleix and Vernois which have been related 
in our remarks on hemorrhage of the new-born, are sufficient to show the 
character of the symptoms in that form of cerebral hemorrhage m which the 
extravasated blood forms a cavity in the interior of the brain. 

If the amount of extravasation be large and the substance of the brain 
be much lacerated and compressed, death may occur almost immediately, and 
therefore without symptoms, or before it is possible to determine whether or 
not symptoms are present. If the disease be not so speedily fatal, the symp- 
toms, as appears from the above cases, are headache, confusion of thought, or 
even insensibility ; cries, sometimes piercing ; cold extremities, pallor, slow 
and perhaps stertorous respiration ; convulsive movements followed by paral- 
ysis, or convulsions affecting one or more limbs, with paralysis of others ; pupils 
contracted or dilated, sometimes one contracted and the other dilated ; stra- 
bismus, rolling of eyes, vomiting. 

These symptoms have all been observed in different cases, but they are not 
all present in any one case. Those which are generally present, and on which 
we mainly rely for diagnosis, are headache, convulsive movements, paralysis,, 
confusion of thought, irregularity in the pupils, and strabismus. 

In the capillary form of cerebral hemorrhage there is usually some com- 
plication, so that it is not easy to determine how far symptoms are due to the 
hemorrhage and how far to the coexisting pathological state. 

There are, indeed, but few published observations of hemorrhage in the 
substance of the brain unaccompanied with meningeal hemorrhage, hemor- 
rhage into a ventricle, or some other distinct disease ; but, so far as I have been 
able to ascertain the symptoms referable to this form of extravasation, they 
are as follows : The child is drowsy ; fretful when disturbed ; it perhaps moans. 
There are sometimes slight convulsive movements and partial paralysis. If 
there be considerable extravasation, the respiration is irregular and sighing. 
Death occurs in coma, occasionally preceded by convulsions. Taupin relates 
the case of a child, nine years old, who died with this form of hemorrhage, 
accompanied by softening of the brain. The disease began at night with delir- 
ium, agitation, and piercing cries. In the morning the patient lay in bed, 
drowsy, not complaining of pain and not replying to questions ; pupils dilated 
and insensible to light ; left eye half open during sleep and its axis changed ; 
eyebrows contracted ; face pale ; mouth open ; had no convulsions, but tran- 
sient stiffening of the limbs, during which the thumbs were firmly compressed 
by the fingers; senses unimpaired, but the face drawn to the right : deglu- 
tition difficult ; pulse small, irregular, and feeble ; respiration 32, sighing. In 



INTRACRANIAL HEMORRHAGE. 587 

the evening he had rigidity of the limbs and back, and finally was taken with 
general convulsions, in which he died at eleven o'clock. The hemorrhagic 
points in this case were numerous. A boy five years old, whose case is de- 
scribed by Rilliet and Barthez, died of this disease, pneumonia, and white 
softening of the intestine. During the last five days there were cerebral symp- 
toms, the chief of which were drowsiness, fretfulness when disturbed, and 
moaning without apparent cause. Another child, whose case is described by 
Rilliet and Barthez. died at the age of four years with cerebral capillary hem- 
orrhage, accompanied hy yellow softening. Six months before death he had 
general convulsions, followed by spasmodic movements of the left side. These 
subsided, but the left side remained feeble. 

In meningeal hemorrhage there are often convulsions, general or par- 
tial—in some patients tonic, in others clonic. When partial, the convulsive 
movements may only occur in the muscles of the face and eyes. With the 
spasmodic muscular action is a degree of drowsiness with irritability. Paral- 
ysis, so common in the apoplexy of the adult, and not infrequent, as we have 
seen, in the cerebral form in early life, is sometimes, but not ordinarily, pres- 
ent in meningeal hemorrhage. Instead of paralysis, there are vomiting, some 
febrile action, thirst, and loss of appetite. The symptoms are different, how- 
ever, according to the exact seat of the hemorrhagic extravasation and the 
duration of the disease. If the extravasation end in the formation of a cyst, 
the symptoms are those of hydrocephalus. The following condensed history 
of cases which I have selected as typical will give us a clearer idea of the his- 
tory and course of the various forms of meningeal hemorrhage than can be 
imparted by a narration of symptoms : 

31. Tonnele relates the case of a child which was taken with faintness and 
convulsive movements. On the following day the trunk and inferior extrem- 
ities became rigid ; deglutition was painful ; the pupils were largely dilated, 
immovable ; face pale ; pulse feeble and intermittent. Death occurred the 
same day. The dura mater was distended. A layer of coagulated blood of 
great thickness extended over the convexity of each hemisphere. The veins 
ramifying into the superior portion of the cerebrum were distended with coag- 
ulated blood. The hemorrhage was in the meshes of the pia mater. Drs. 
Lombard and Pane-hard of Geneva relate a somewhat similar case. A child 
thirteen months old was convalescing from inflammation of the bronchial and 
intestinal mucous surfaces when it was seized with general convulsions ; the 
mouth and eyes were open and the eyes directed upward ; pupils contracted ; 
pulse frequent and irregular. The convulsions abated somewhat, but soon 
reappeared with violence. The patient became insensible, and died nineteen 
hours after the commencement of cerebral symptoms. The extravasated blood 
covered the upper surface of both hemispheres. From the above cases we see 
the symptoms and the course of meningeal hemorrhage when the extrava- 
sation is so large that death speedily results. In protracted cases of menin- 
geal hemorrhage there is either a gradual disappearance of symptoms and 
return to health, or, circumscribed hydrocephalus occurring, the symptoms of 
that disease arise. 

Diagnosis. — It is evident, from what has been stated, that the diagnosis 
of intracranial hemorrhage is attended with unusual difficulty, since the 
symptoms of this disease occur also in other and distinct pathological states. 
The history of the case, and especially the character of the cause, if ascer- 
tained, will aid in diagnosis. If there have been an obvious determination 
of blood to the brain or some known obstruction to the return of blood from 
that organ, the persistence of cerebral symptoms would justify us in con- 
cluding that either serous or sanguineous effusion had supervened on a state 
of congestion. The points of differential diagnosis between apoplexy and 



588 LOCAL DISEASES. 

meningitis are the sudden and full development of symptoms in one case, 
the gradual commencement and gradual increase of symptoms in the other; 
differences also of symptoms in certain respects ; for example, as regards 
fever, constipation, etc. 

There is one symptom in cerebral hemorrhage which is of great diagnostic 
value — namely, paralysis. Its presence affords strong evidence that there is 
extravasation of blood, and probably in a cavity of the substance of the brain. 
If the extravasation end in the formation of a cyst, the symptoms and appear- 
ance of hydrocephalus, which after a time arise, throw light on the nature 
of the disease. 

Prognosis. — There can be no doubt that many cases of intracranial 
hemorrhage occur and terminate favorably without the nature of the disease 
being suspected. In such cases the amount of extravasated blood is small 
or moderate. In several published cases in which the accuracy of the diag- 
nosis was shown by post-mortem examinations, the patients were convalescing 
from the hemorrhage when they succumbed to intercurrent disease. If, 
however, the amount of extravasated blood be such as to give rise to those 
symptoms which have been described, the prognosis is unfavorable. Recur- 
ring convulsions and persistent stupor from which it is difficult to arouse the 
patient are unfavorable symptoms. If the convulsions cease and conscious- 
ness return, even if there be paralysis, the result may be favorable, 

Treat3IENT. — The proper treatment in intracranial hemorrhage depends 
on the state of the patient, the time which has elapsed since the extravasa- 
tion, and the degree of it as shown by the nature and severity of the symp- 
toms. If, as is often the case, the patient be robust and be visited soon after 
the commencement of the attack, cold applications should be made to the 
head, mustard to the back of the neck and perhaps chest, and derivation 
should be produced by mustard pediluvia. In active congestion prompt pur- 
gation by salines or other cathartics is sometimes of great importance. The 
object of such treatment is to relieve congestion of the cerebral and meningeal 
vessels, and thereby prevent further extravasation of blood. If the conges- 
tion be active, the pulse continue full and frequent, and the face be flushed, 
it is proper in many cases to control the action of the heart by a sedative. 
For this purpose the tincture of aconite-root may be given in doses of one 
drop to a child five years old, repeated in three hours, or a more prompt 
sedative, as phenacetin, may be given. If the stupor or convulsions continue 
after sufficient time have elapsed for the patient to receive the full benefit 
of the above remedies, more counter-irritation is required. Cantharidal col- 
lodion should be applied behind each ear. If the hemorrhage occur from 
passive congestion or in a cachectic state of system, active depressing reme- 
dies should not be employed. External derivatives are of service, as well as 
cool applications to the head, and we should attempt, as far as possible, to 
remove the cause of the congestion and hemorrhage. If it depend on a 
cachectic state, tonic or other remedies calculated to relieve this state are 
indicated. The hemorrhage from such a cause is usually in points in the 
substance of the brain or in moderate quantity over the surface of this organ, 
and by a timely use of constitutional remedies possibly we may prevent further 
extravasation of blood and increase the chance of the patient's recovery. 

If a cyst result from the hemorrhagic effusion, the treatment which is 
proper is that described in the chapter on Acquired Hydrocephalus. 



CONGENITAL HYDROCEPHALUS. 589 

CHAPTER III. 

CONGENITAL HYDKOCEPHALUS. 

Congenital hydrocephalus consists in an excess of the cerebro-spinal 
fluid, lying either external to the brain or more frequently in its interior. 
It is due to some vice in the development of the brain or its membranes or 
to a pathological state occurring in them during intra-uterine life. This 
disease is in some patients apparent from the symptoms and appearances at 
birth, but not always. Occasionally nothing unusual is observed in the 
shape of the head or aspect of the infant till after the lapse of some weeks, 
when the characteristic physiognomy begins to appear. In these cases the 
disease is still congenital, since there is every reason to believe that the 
abnormal state to which the excessive production of fluid is due existed 
from birth. In cases of arrested or partial development of the brain — as, 
for example, when a considerable portion of the hemispheres is absent — there 
is often an unusually large quantity of fluid which serves as a compensation 
for the lack of brain. I do not regard such cases as examples of hydro- 
cephalic disease, since the effect of the fluid is not injurious, but rather 
useful. I restrict the term congenital hydrocephalus to those cases in which 
the brain is complete, or, if incomplete, the quantity of fluid is more than 
sufficient to supply the deficiency. 

Anatomical Characters. — According to M. Breschet, the fluid in con- 
genital hydrocephalus may be — 1st, between the dura mater and the cranium ; 
2d, between the dura mater and the parietal arachnoid ; 3d, in the cavity of 
the arachnoid ; 4th, in the ventricles ; 5th, between the arachnoid and the 
brain. 

In a large majority of hydrocephalic patients the effusion occurs in the 
ventricles. As the quantity of fluid increases, the pressure from within grad- 
ually unfolds the convolutions of the brain, at the same time producing expan- 
sion of the cranial arch. When the amount of fluid is considerable — and it 
becomes so in the course of a few weeks or months — the hemispheres are 
spread out in a thin lamina on either side, gradually decreasing in thickness 
from the base of the cranium to the vertex, where the brain-substance is 
sometimes so thin as to be scarcely perceptible. Complete absence of brain 
in this situation — namely, at the vertex, even in extreme cases of expansion 
and flattening of the hemispheres from the pressure of the liquid — is rare, 
though the brain-substance at this point is sometimes almost as thin as either 
of the membranes, so that the wall of the sac is translucent. The membranes 
which surround the brain do not usually undergo any alteration, except such 
as arises from the distention. The falx cerebri sometimes disappears, and 
sometimes the meninges present a whiter hue from maceration than in health. 
The distention also causes such an expansion of the pia mater that it becomes 
very thin, and in places scarcely visible, but its presence in every point can 
be demonstrated. 

The accompanying woodcut represents congenital hydrocephalus as it ordi- 
narily occurs. I saw this infant when it was a few days old, and examined 
it from time to time till its death. The parents are healthy and have other 
healthy children. This infant when nine days old began to have clonic convul- 
sions of a mild form in the muscles of the face, neck, and limbs, which occurred 
almost daily till the age of six weeks, and sometimes every five or ten minutes. 
When the convulsions ceased in the sixth week the head was observed to 
enlarge, and its excessive growth continued till death, which occurred at the 



590 



LOCAL DISEASES. 



age of seven months and one week. "While the volume of the head progres- 
sively increased, the trunk and limbs emaciated. At death the occipitofrontal 
circumference of the head was nineteen and a half inches ; the vertical from 
auditory meatus to meatus, thirteen and a half inches. 

The changes which the cranial bones undergo, both in their chemical 
character and in their shape, in hydrocephalic patients, if the amount of fluid 

Fig. 188. 




be considerable, are interesting and remarkable. The base of the cranium 
undergoes little change, but those portions of the frontal, parietal, and occip- 
ital bones which constitute the arch are expanded in all directions, while they 
become much thinner. There is deficiency of lime in their constitution, so 
that the organic elements are greatly in excess. This renders them flexible 
and semi-transparent. Notwithstanding the expansion of the bones, there are 
usually interspaces between them, of greater or less size according to the 
amount of fluid. 

The scalp, being stretched by the pressure underneath, becomes tense and 
thin, and is scantily covered with hair. The veins which ramify in it are 
unusually prominent and large, and the head is elastic on pressure from the 
amount of liquid beneath. In the common form of congenital hydrocephalus 
— namely, that in which the liquid is in the interior of the brain — the shape 
of the orbital plates of the frontal bone is often changed, so that the eyeballs 
have a downward direction. This change in the axis of the eyes occurs at 
an early period, and it continues through the entire disease, becoming more 
and more marked as the quantity of liquid increases. If the amount be 
large, the lower part of the cornea is buried under the under eyelid, while 
the conjunctiva is visible between the cornea and the upper eyelid. The per- 
sistent downward direction of the eyes is characteristic of this disease, and in 
connection with enlargement of the head is an important diagnostic sign. 
Nevertheless, hydrocephalus, even of the ventricular variety, sometimes 
occurs without change in the direction of the eyes. 

If we examine the interior of the cavity after the fluid is evacuated, we 
will find at its base the parts which lie in the floor of the lateral ventricles, 
but changed in appearance in consequence of pressure. The cornua are 
enlarged and the thalami optici and corpora striata are flattened. In the 



COXGEXITAL HYDROCEPHALUS 



591 



early stages of the disease, when the amount of fluid is small, there is prob- 
ably no absorption or destruction of parts in the interior of the brain. The 
various portions of this organ retain nearly their normal relation to each 
other. As the quantity of fluid increases the foramen of Monro, which unites 
the lateral ventricles, becomes enlarged, the septum lucidum which separates 
them disappears, and the two ventricles form a common cavity. In most fatal 
cases we find this single large cavity. The surface which surrounds the cavity 
occasionally presents a whitish or semi-opaque appearance, which has led to the 
belief that at a period antecedent to birth there was subacute inflammation 
of this surface, and hence the effusion. 

The bones of the face are ordinarily less developed than in healthy chil- 
dren of the same age, so that the disproportion between the head and face 
becomes a marked peculiarity. The shape of the forehead and face is nearly 
triangular. 

The foregoing remarks in reference to the anatomical characters of con- 
genital hydrocephalus refer in the main to cases which have continued for a 
considerable time, so that their characteristic features are well marked. In 
very young infants, in whom the disease is still recent, similar anatomical 
characters are present, but in less degree. 

Congenital hydrocephalus is often associated with other vices of confor- 
mation, especially with spina bifida. The two, when coexisting, are only parts 
of the same disease, the large quantity of cerebro-spinal fluid preventing the 
spinal canal from closing during foetal development. 

The fluid in congenital hydrocephalus consists largely of water, in the 
proportion even of 99 parts in 100. In addition to this element there are 
traces of albumen, chloride of sodium, phosphate and carbonate of sodium, 
and osmazome. 

I have had an opportunity to witness only one post-mortem examination 
in a case of congenital hydrocephalus in which the liquid was exterior to the 
brain. This case was under observation in the children's service of Charity 
Hospital in 1866. Full notes and measurements of the head were taken, 
which, unfortunately, were mislaid or lost. The infant had congenital syph- 
ilis and had a pallid, strumous appearance. The shape and relative size of 
the head are seen in the woodcut (Fig. 189), from a photograph. While the 
whole head was enlarged, there was a relative excess of development in the 
part between and above the ears. The axis of the eyes was not changed, and 
the vision was good. The appearance corresponded so closely with descrip- 
tions of hypertrophy of the brain that this was supposed to be the anatomical 
state. Antisyphilitic treatment was employed, and 
the syphilitic eruptions had disappeared when 
diarrhoea supervened, followed by death. At the 
autopsy a quantity of transparent or light straw- 
colored liquid, estimated at six or seven ounces, 
was found exterior to the brain in the great cavity 
of the arachnoid, lying mostly over the superior 
surface of the organ. There was no excess of liquid 
in the ventricles, and the brain, though of good size, 
was not abnormally large, nor did it possess the 
firmness which is present in true hypertrophy. 

All cases of congenital hydrocephalus may be 
embraced in two groups — namely, that in which 
the liquid is in the interior of the brain, and that 
in which it lies exterior to the organ. Liquid pri- 
marily in the arachnoidean cavity permeates the 
meshes of the pia mater, and lies in part underneath it, or this delicate mem- 



Fig. 189. 




592 LOCAL DISEASES. 

brane may be ruptured. Four of the groups, therefore, described by Breschet, 
may properly be reduced to one — namely, those groups in which the liquid 
lies under, between, or external to the meninges. It is probable that some of 
the cases which led to Breschets classification were examples of acquired 
circumscribed hydrocephalus, the result of extravasation of blood. 

Etiology. — The constitutional vice which gives rise to this disease is 
probably different in different cases. I have been able, I think, to attribute 
correctly a considerable proportion of cases which I have observed to con- 
genital syphilis, but in other instances from the character of the parents I 
could not assign this cause. 

Symptoms. — If there be a considerable amount of hydrocephalic fluid 
prior to the birth of the child, so that the head is abnormally large, partu- 
rition is seriously interfered with. The scalp and meninges may become 
ruptured by the severity of the pains, so that the fluid escapes. If this do 
not occur, the labor is often necessarily instrumental. Whether the liquid be 
present before birth or accumulate subsequently to it, the tendency is to an 
increase of the quantity and a corresponding enlargement of the head. 

The digestive function in this disease is at first well performed. The 
infant nurses readily and has its evacuations with the regularity of other 
children. Not many weeks, however, elapse, in the majority of cases, before 
defective nutrition is apparent. 

While the volume of the head increases, other parts are imperfectly nour- 
ished and stunted in their growth. Emaciation of the neck, trunk, and 
limbs is common, associated with progressive feebleness. In the last stages 
of this disease there is more or less vomiting, with constipation. If there 
were previously the ability to support the head, it is now lost, and the erect 
position is no longer possible. In marked cases, when there is great dispro- 
portion between the head and the rest of the system, there is frequently not 
even the ability to rotate the head on the pillow. So long as the cranial 
bones yield readily to the pressure from within and there is no compression 
of the brain, the function of this organ is not seriously impaired. The child 
recognizes its mother or nurse, and it can be amused like other children, 
though easily fatigued. The state of the senses is different in different cases, 
and sometimes at different stages of the same case. The sight and hearing 
in some are perfect, in others impaired, while in others still they are good at 
first, but gradually become obscured and lost. It is said that the sense of 
smell may be perverted, so that agreeable odors are unpleasant, and vice versa. 
Many, reaching the age at which children begin to walk, cannot walk, or, if 
they do, it is with a tottering, unsteady gait. 

When the liquid increases to that extent — and it usually does sooner or 
later — that the brain begins to be compressed, dangerous cerebral symptoms 
arise. The child becomes drowsy and takes less notice of objects. Spas- 
modic muscular contractions, and finally convulsions, occur. The pupils act 
feebly or irregularly by light, or one is more dilated than the other. Strabis- 
mus also occurs. As death approaches, eclampsia, partial or general, be- 
comes more frequent, and is succeeded by stupor from which the patient 
cannot be aroused. 

The following; case, which I copy from my note-book, is an example of the 
common form of congenital hydrocephalus ; it will aiye an idea of the ordinary 
course of this disease, and show the difficulty which we meet with in its treatment : 
Female, born November 9, 1859, with the aid of forceps. At birth the fontanelles 
were unusually large, the cranial bones separated, and the aspect in a marked de- 
gree hydrocephalic. She nursed at first, but, the mother's milk failing, she was 
afterward bottle-fed. At the age of four months her head, which had increased 
faster than her general growth, measured from one auditory meatus to the other, 



CONGENITAL HYDROCEPHALUS. 593 

over the vertex, seventeen inches ; the occipitofrontal circumference, twenty-three 
inches. At this time she manifested considerable intelligence, being able to distin- 
guish her mother from other persons, though the head was so large that it was 
necessary to support it constantly on a pillow. From the age of four to six months 
the operation of tapping was performed six times with a small hydrocele trocar by 
Dr. Stephen Smith, at a point near the coronal suture and from one inch to one 
inch and a half from the sagittal. At each operation an amount of fluid varying 
from twelve ounces to one pint was removed, and the head then covered with strips 
of adhesive plaster, so as to form a complete cap. It was necessary, however, 
within the twelve hours succeeding each operation to loosen the dressing on account 
of either the occurrence of convulsions or symptoms premonitory of them. The 
head within a week subsequently to each operation regained its former size, and, as 
there was no permanent benefit, this treatment was discontinued. She finally died 
of entero-colitis at the age of ten months and five days. 

At the autopsy the distance from one auditory meatus to the other was twenty 
and a quarter inches : the occipitofrontal circumference, twenty-six and a quarter 
inches. The anterior fontanelle measured antero-posteriorly four and three-fourths 
inches : transversely, seven and three-fourths inches. The parietal bones were 
separated from each other to the distance of two or three inches, and they measured 
in length nine and a half inches. 

On opening the cranial cavity, seven pints, by measurement, of transparent 
fluid escaped, exposing a vast open space at the bottom of which were the parts 
which constitute the floor of the ventricles, somewhat changed in shape, and from 
them on either side the hemisphere was spread in a lamina, so as to cover the 
internal surface of the cranial bones. The laminae near the base of the brain 
measured in thickness from half an inch to one inch, and they gradually became 
thinner on approaching the vertex, at which point the brain-substance was ex- 
ceedingly thin, so as to be scarcely demonstrable. 

The brain had its normal vascularity and consistence, and the cerebellum, 
medulla oblongata, the base of the brain, and cranial nerves presented their usual 
appearance. On folding the brain together, it had the size, shape, and aspect of 
this organ in its ordinary development. Nothing unusual was observed in the 
membranes except their great expansion. The above case corresponds in its gen- 
eral features with most cases met in practice. 

Diagnosis. — The ordinary form of congenital hydrocephalus, that in 
which the liquid occupies the interior of the brain, can in most cases be 
readily diagnosticated. If there be only a moderate amount of liquid, it 
may be confounded with hypertrophy of the brain. In hydrocephalus there 
are commonly more rapid growth and greater expansion of the head ; more- 
over, the enlargement occurs equally on all sides, while in hypertrophy, 
though all parts of the cranial vault are expanded, the enlargement is more 
at the vertex than elsewhere. The hydrocephalic head yields more readily 
to pressure than the hypertrophied, and often communicates a fluctuating 
sensation. Moreover, in the ordinary form of hydrocephalus the change in 
the axis of the eyes described above is an important diagnostic sign. In 
rachitis the volume of the head is often considerably enlarged, due some- 
times, in part at least, to a deposit of calcareous matter on the exterior of 
the cranial bones. The differential diagnosis is based on the shape of the 
head, round in one, square or with prominences in the other, on palpation, 
direction of the eyes, etc. The smaller the amount of liquid, the greater 
the liability to error of diagnosis ; but if the amount be inconsiderable and 
not increasing, little treatment is required except hygienic and tonic, which 
is also proper in both hypertrophy and rachitis. If the liquid be exterior to 
the brain, as in the case represented in Fig. 189, diagnosis may be difficult. 
but such cases are infrequent. 

Prognosis. — In the majority of the cases this is unfavorable, since the 
secretion of liquid usually continues. The most favorable result is no in- 
crease, or but slight, in the quantity, while the natural growth of the infant 
38 



594 LOCAL DISEASES. 

increases, and thus the disproportion between the head and the rest of the 
system gradually disappears. Such patients may live to maturity and have 
tolerable health, and may engage in occupation. But ordinarily in cases left 
to themselves, and even in a large proportion of those having the best treat- 
ment, the body and limbs gradually waste from defective nutrition, and the 
patient, if not cut off by an intercurrent disease, finally succumbs with cere- 
bral symptoms produced by pressure of the liquid. Probably more than 
half of the hydrocephalic patients die before the close of the second year. 

Treatment. — We may attempt to diminish the quantity of fluid by the 
use of diuretics. Digitalis, squills, nitrate and acetate of potassium have 
been used. The most efficient diuretic in these cases, however, is the iodide 
of potassium. This may be given in doses of one to two grains every two 
hours to an infant of three months. Constipation, if present, should be 
relieved by an occasional purgative. If it be tolerated, we may partially 
prevent the expansion of the head by a close-fitting cap. For this purpose 
strips of adhesive plaster, about one-third of an inch in width, should be 
applied so as to cover the entire head. The proper way of applying these is 
as follows : First, one strip from each mastoid process to the outer part of 
the orbit on the opposite side ; secondly, from the back of the neck, along 
the longitudinal sinus, to the root of the nose ; thirdly, over the whole head, 
so that the different strips will cross each other at the vertex ; and, lastly, a 
strip long enough to pass three times around the head should be applied, 
passing above the eyebrows, the ears, and below the occipital protuberance. 
Too tight an application should be avoided, as it may give rise to convul- 
sions or other cerebral symptoms. If the cap can be tolerated and the gen- 
eral health be good, the prospect is more favorable ; but usually, from the 
increase in the quantity of fluid, it is necessary in a few days to remove or 
loosen the strips in order to prevent convulsions, or, which is preferable, to 
diminish the size of the head and relieve the pressure by tapping. In 56 
cases collected by Dr. West in which tapping was employed, 4 recovered. 
The operation is simple, easily performed, devoid of danger, and it frequently 
gives temporary relief. It should therefore be recommended to the parents, 
even if it do not effect a cure. It should be performed by a very small 
trocar, which should be introduced in the coronal suture, about an inch ex- 
ternal to the anterior fontanelle. A few ounces should be removed, and strips 
of adhesive plaster or an elastic skull-cap applied. In a few days the opera- 
tion should be repeated as the liquid increases. It is important to maintain 
compression of the skull before and after the operation (Treves). Some- 
times a dozen or more tappings are required at intervals of a few days or 
weeks, when the secretion may come to a standstill. In the Med.-Chir. 
Trans. (1864) a case is related in which two tappings effected a cure, but so 
good a result is exceptional. Iodine injections in connection with tapping 
have so far not produced any satisfactory result. Sir James Paget 1 relates 
a case in which he injected ten grains of iodine and twenty grains of iodide 
of potassium in one ounce of water, but the child died of convulsions after 
the second injection. No appreciable good result has followed the use of 
irritating or sorbefacient applications to the head. Nutritious diet and atten- 
tion to the general health are requisite. 

1 Medical Times and Gazette, 1860. 



ACQUIRED HYDROCEPHALUS. 595 

CHAPTER IY. 

ACQUIRED HYDROCEPHALUS. 

Hydrocephalus, or dropsy of the brain, may also occur in those who at 
birth are well formed and free from disease. Pathologists call this acquired 
hydrocephalus. It is in nearly all cases the result of disease, which is 
located sometimes within the cranium, but often in other parts of the system. 

Causes. — The diseases within the cranium which most frequently produce 
serous effusion are the meningeal inflammations, both simple and tubercular, 
tumors or other causes which obstruct the venous circulation, and hemor- 
rhagic effusion ending in the formation of cysts. Prolonged passive conges- 
tion often ends in transudation of serum through the coats of the capillaries. 
Therefore, all causes of congestion, except such as have a transient or 
momentary effect, may be regarded as causes of serous effusion. In rare 
instances chronic hydrocephalus results from cerebro-spinal fever (menin- 
gitis), as has been stated in my remarks on the latter disease. 

Among the diseases external to the cranium which produce serous effu- 
sion within or upon the brain may be mentioned retropharyngeal abscess, 
tuberculization or inflammation of the bronchial glands, scarlet fever, and 
certain affections of an exhausting nature, especially protracted diarrhceal 
maladies. In at least five cases which have fallen under my notice, and in 
which post-mortem examinations were made, the cause was enlarged tuber- 
cular bronchial glands, which, by pressure on the venae innominatae, so 
retarded the flow of blood from the brain as to cause congestion and effu- 
sion. The causal relation of these glands to cerebral congestion is described 
in our remarks in reference to this disease. 

Dropsy of the brain is common in protracted infantile diarrhoea ; as, for 
example, in advanced cases of intestinal catarrh of the summer months in 
the cities. It is preceded and accompanied by passive congestion of the cere- 
bral veins and sinuses, due in part to feebleness of circulation in consequence 
of the exhausted state of the patient, and in part to wasting of the brain, 
which always give rise to more or less passive congestion, unless in young 
infants, in whom the cranial bones become depressed and override each other. 
Dropsy of the brain, resulting from scarlet fever, and that peculiar circum- 
scribed dropsy which results from hemorrhagic effusions, are described else- 
where. But the most severe and injurious form of acquired hydrocephalus 
is that which results from cerebro-spinal fever, since it causes great and in- 
creasing cranial expansion and loss of sight, and sometimes of hearing. 

A few cases have been related by different observers, Abercrombie among 
others, in which the dropsy of the brain seemed to be essential. Nothing 
abnormal was observed except the serous effusion. But the reports of such 
cases are, for the most part, meagre, and, as Barrier has well said, we are not 
to accept such cases as examples of essential dropsy of the brain unless the 
post-mortem inspection be so complete as to render it certain that there was 
no pathological state which might cause the dropsy. 

Anatomical Characters. — Acquired hydrocephalus usually occurs 
after the cranial bones are firmly united, and therefore the shape of the head 
is not materially altered. If it occur at an early age, before there is firm 
union, there may be expansion of the cranial arch, as we sometimes observe 
in the circumscribed hydrocephalus resulting from hemorrhage. The effu- 
sion in acquired hydrocephalus occurs over the surface of the brain, in the 
subarachnoid space, or in the lateral ventricles. In the dropsy of protracted 



596 LOCAL DISEASES. 

diarrhoeal maladies I have rarely failed to find the liquid over the whole 
superior surface of the brain as well as at its base. 

The quantity of fluid in this disease is not large. In the majority of 
cases it does not exceed four ounces and is often much less. It is trans- 
parent or it has a slightly yellowish tinge. The membranes of the brain 
sometimes present their normal appearance, but in other cases they are 
injected. The brain itself in some instances has an injected appearance from 
passive congestion of the veins and capillaries ; but in others, when there has 
been more or less compression of the brain, there is no more than the ordi- 
nary, or even less than the ordinary, vascularity, and the convolutions are 
somewhat flattened. 

Symptoms. — The symptoms of the pathological state which gives rise to the 
dropsy precede and accompany those which are referable to the dropsy itself. 
The dropsy declares itself by symptoms which are alarming from the first. 

In children old enough to speak or manifest intelligence there may be at 
first complaint of headache. The child is irritable, its mind confused or wan- 
dering at times, or there is actual delirium. After a time drowsiness occurs. 
The head seems too heavy for the body and is buried in the pillow. In fatal 
cases the features become pallid, the pupils sluggish, and perception and 
consciousness are gradually lost. The child lies in profound sleep, which 
increases. There are now often convulsive movements, partial or general, 
and these soon end in coma, in which the patient dies. 

In January, 1890, 1 exhibited to the New York Pediatric Society a child 
with acquired hydrocephalus which dated back to an attack of cerebro-spinal 
fever of mild type that occurred a few months previously. 

Prognosis. — Acquired hydrocephalus commonly ends unfavorably. The 
prognosis depends not only on the quantity of liquid, but on the nature of 
the cause. If the cause be venous obstruction within the cranium or thorax, 
death is inevitable, since we have no means of removing it. If it be an ex- 
hausting disease, as entero-colitis or scarlet fever, although the case is not 
absolutely hopeless, the prospect is still unfavorable. It is only favorable 
when the quantity of effused fluid is small, the system not much reduced, 
and the primary disease mild. When acquired hydrocephalus arises from 
meningeal apoplexy, the case is usually chronic. 

The symptoms and termination of this form of the disease are very 
similar to those in congenital hydrocephalus. 

Treatment. — The treatment in acquired hydrocephalus must vary in 
different cases according to the nature of the disease on which it depends. 
I shall indicate the treatment, in part, at least, in the description of these 
diseases. Occasionally the condition of the patient is such that no material 
improvement can result from any mode of treatment. 



CHAPTER V. 

MENINGITIS (TUBERCULAR AND NON-TUBERCULAR). 

The most interesting and important disease of the cerebro-spinal system 
in early life is that which is now designated meningitis. It is not infrequent. 
The mortuary statistics of this city show that it is the cause of death in from 
1 in 25 to 1 in 50 of the entire number of deaths, the proportion varying 
somewhat in different years. 



MENINGITIS. 597 

In 1768 the attention of the profession was particularly called to this 
malady by Dr. Whytt of Edinburgh. This observer and the pathologists 
succeeding him. forming their opinion of meningitis from its most prominent 
anatomical character — namely, serous effusion — believed it a dropsy. They 
accordingly designated it acute hydrocephalus. The disease is now properly 
regarded as inflammatory, and hence the name by which its true pathological 
character is expressed. Inflammation limited to the dura mater has been 
designated pachymeningitis, in consequence of the thickness of this mem- 
brane ; and that affecting the thin and soft membranes, the pia mater, and 
arachnoid has for a similar reason been designated leptomeningitis. 

Sometimes meningeal inflammation in children occurs without tubercles. 
In other instances it results from the presence of tubercles, and in most, if not 
in all, such patients there are tubercles in or under the meninges, which excite 
the inflammation in the same manner as in the lungs they cause pneumonitis 
or pleuritis. Therefore two forms of meningitis are recognized — to wit, tuber- 
cular and non-tubercular. Meningitis is also, as we have seen, the characteristic 
anatomical character of cerebro-spinal fever, but as this is a general disease, 
with the meningitis as a local manifestation, we have treated of it among the 
constitutional maladies. 

In patients over the age of eighteen months, although the proportion of tuber- 
cular to non-tubercular cases is larger than under this age, the excess is not so 
great, according to my statistics, as the remarks of some observers lead us to sup- 
pose. There can be no accurate statistics of tubercular meningitis without careful 
post-mortem examination of the state of the brain and other organs in each supposed 
case, and this examination sometimes shows the meningitis to be non-tubercular 
when the symptoms and signs had indicated its tubercular character. As an example 
may be mentioned a case which occurred in the children's service of Charity Hos- 
pital in March. 1868. The infant died at the age of twenty months, having had a 
cough of moderate severity at least three weeks before death, and symptoms of 
meningitis about four days. It was considerably wasted, and was supposed to have 
tuberculosis. At the autopsy no tubercles were found in any part of the body, but 
portions of both lungs were hepatized. A fibrinous deposit, varying in thickness, 
was found over the pons Varolii, the optic commissure, along the fissures of Sylvius, 
over the superior surface of the anterior half, and also upon the superior lobe of each 
cerebral hemisphere. As the examination failed to disclose any tubercles, the menin- 
gitis was considered non-tubercular. Those who make these examinations, failing 
to find tubercles in the lungs and other organs in which they usually occur, should 
examine the lymphatic glands, since cheesy glands may be the cause of the forma- 
tion of tubercles in the meninges, while the organs of the trunk remain unaffected. 
The presence of cheesy glands in the absence of visceral tubercles and with granu- 
lations upon the meninges, small, covered with fibrin, and of a doubtful character, 
goes far toward establishing the tubercular nature of the meningitis. Since the 
cases embraced in the following statistics were observed, now more than twenty 
years ago, I have been led by a more extended experience, and especially by the ob- 
servation of cases in the New York Foundling Asylum, where there is ample mate- 
rial, to regard not only the presence or absence of tubercles, but also of caseous 
substance, as the proper test of the form of meningitis. Not a few that seem at first 
to have non-tubercular meningitis will be found, on more thorough examination, to 
have caseous substance in some part, the result of a pre-existing inflammation ; and 
if we regard the inflammation of the meninges occurring under such circumstances 
as tubercular, the relative proportion of tubercular cases will be considerably aug- 
mented. The following is an example: When on duty in the asylum in August. 
1881, an infant one year old died of meningitis. No tubercles were observed in 
the fibrin at the base of the brain and along the fissures of Sylvius, but one inflam- 
matory nodule (cerebritis) as large as a chestnut, with suppuration inside. Avas found 
at the summit of one hemisphere. No tubercles could be detected in any of the 
organs of the trunk, unless a few whitish spots in the spleen were of this nature, 
but the bronchial glands were cheesy and softened, and the middle lobe of the right 
lung also contained cheesy substance. It seemed to me probable that some of this 



598 LOCAL DISEASES. 

degenerated product taken up by the vessels had lodged in the meninges and pro- 
duced the tubercular neoplasm "there which was hidden under the fibrin. (See 
chapter on Tuberculosis.) 

Age. — The following table gives the age in meningitis, tubercular and 
non-tubercular, in forty-two cases in my collection, which is a small propor- 
tion of those which I have observed ; but these are the only cases of which 
I have preserved notes : 

Cases. Age. 

1 2J weeks (autopsy). 

'2 3 months. 

20 From 3 to 12 months. 

10 From 1 year to 2 years. 

5 From 2 years to 5 years. 

4 Over 5 years. 

42 

Rilliet and Barthez have also published statistics of the age in meningitis. 
Their cases were observed chiefly in hospital practice, and the result is somewhat 
different. In 32 cases of non-tubercular meningitis observed by these authors, 8 
were under the age of one year, 6 from two years to five, and 18 over the age of five 
years. In 98 cases of tubercular meningitis, 2 were under the age of one year, 51 
between the ages of one year and five, 38 between the ages of five years and ten, 
and 7 between ten and fifteen years. Growers states that the age at which menin- 
gitis is most frequent is between the first and tenth years. 

Pathological Anatomy. — This differs considerably in different cases. 
The dura mater is usually unaffected or is affected secondarily. In many 
cases it retains its normal appearance, its internal surface remaining smooth 
and polished, while in others it is more or less injected and its internal sur- 
face dim or lustreless. The free surface of the pia mater, formerly designated 
the visceral arachnoid, is in a great part of its extent unchanged, but is often 
hyperasmic or dry and cloudy or opaque over the seat of inflammation. Exu- 
dation does not occur upon the free surface of the pia mater, however intense 
the inflammation. 

In meningitis, tubercular and non-tubercular, the inflammatory action 
occurs in the pia mater. In its meshes or underneath them those lesions 
result which characterize the disease, and to which other lesions are secondary. 
Tubercular meningitis is most frequently basilar, or is basilar chiefly and pri- 
marily, although the inflammation may extend along the sides of the hemi- 
spheres. The meningitis is ordinarily most intense around the pons Varolii, 
in the subarachnoid space, and along the fissures of Sylvius, for the tubercular 
neoplasm occurs chiefly at the base of the brain and along the vessels. In 
non-tubercular meningitis the inflammation may also occur at the base. It 
may in young infants be quite diffuse, and of little intensity in any one place, 
producing, in addition to hyperaemia of the pia mater, slight cloudiness and a 
moderate or slight escape of leucocytes from the blood, these (pus-cells) being 
perhaps visible only under the microscope. In meningitis due to extension 
of inflammation from an otitis media the inflammatory action is intense, con- 
fined to the portion of the meninges nearest the ear, and is often attended by 
inflammation of the adjoining brain-substance, with perhaps the formation of 
an abscess. If the cause be exposure to the sun's rays or traumatism, the 
meningitis is usually at the summit of the brain. 

The exudation of fibrin is greatest along the course of the vessels and in 
the depressions between the convolutions, and the opacity is most marked in 
these situations. Pus, when present, is often semi-solid, from the small pro- 
portion of liquor puris which it contains, even in recent cases. If the disease 



MENINGITIS. 599 

have continued several days, the liquor puris may be mostly absorbed, and the 
pus-cell, becoming shrivelled, irregular, and aggravated, may resemble closely 
the cheesy transformation of tubercle-cells. 

The fibrinous exudation presents features of interest. It does not usually 
attain much thickness, but by its opacity it conceals from view the brain 
underneath. If it occur in the fissures of Sylvius, the anterior and middle 
lobes are united by it. It is usually infiltrated through the substance of the 
pia mater. Sometimes little masses of variable size, often not as large as a 
pin's head, appear at the point of inflammation. These masses are firm, of a 
whitish color or a light yellow, and their number varies in different cases. 
They consist of a firm, homogeneous substance containing granular matter 
and cells which often bear a close resemblance to tubercle-corpuscles, but are 
distinct. These corpuscular bodies are plastic nuclei or plastic cells, often 
shrunken. It is seen. then, there are two morbid products which may be mis- 
taken for tubercles — one. pus which has been in great measure deprived of its 
liquid element, and which may resemble cheesy tubercular matter; the other, 
plastic nuclei collected in little bodies, so as to resemble the ordinary form of 
crude tubercle. I once carried to one of the best microscopists and pathologists 
of Xew York some of the exudation from a case of meningitis, the cellular 
element in which could not readily be distinguished from shrunken tubercle- 
corpuscles. The exudation was from a child two years and eight months old, 
with good health previously to the meningitis, without tubercles in any part 
of the body, with parents healthy, and with no predisposition to tubercular 
disease. The microscopist, not knowing the history of the case or character 
of the family, and ignorant, like all of us at that time, of the true tubercle- 
cell, pronounced the exudation tubercular after a careful examination with 
the microscope. 

In the tuberculosis of young children I have found in a large proportion 
of cases in which I have had an opportunity to make post-mortem exami- 
nations miliary tubercles disseminated through the lungs and perhaps other 
organs in small masses, many of them not larger than a pin's head, and some 
occurring as mere specks scarcely visible. These minute tubercular formations 
have ordinarily been semi-transparent, and sometimes even transparent like 
minute drops of water, and containing the true and unchanged tubercle bacil- 
lus. Now, if in such a case meningitis occur, we may find the tubercle-cell 
in or with the fibrin at the base of the brain. But failure to find it, even with 
protracted microscopic examination, does not prove its absence from this 
locality, for I consider it almost impossible to discover in the midst of the 
fibrinous exudation such minute points of tubercular matter as are seen in 
the lungs, liver, or elsewhere. 

The pia mater is often firmly adherent to the brain at the seat of inflam- 
mation, so that on raising it a portion of the brain may be detached and re- 
moved with it. The extent of the inflammation varies much in different cases. 
There may in extreme cases be pretty general inflammation of the pia mater. 
In cases of such extensive meningitis the symptoms are usually severe and 
the course of the disease rapid. 

Thus, in the month of April, 1866, a girl eleven years of age, in the Protestant 
Episcopal Orphan Asylum of this city, had complained occasionally of dizziness, 
but was otherwise in good health, cheerful and w 7 ith excellent appetite, till Thurs- 
day, when she was affected with vertigo, more persistent than previously, and with 
headache. At 2 p. m. on the following day she was seized with general convulsions, 
and continued insensible or nearly so, with occasional convulsive movements, till 
Monday, when she died comatose. The pia mater at the vertex, sides, and base of 
the brain had a cloudy appearance, and underneath it in places was a thick, creamy 
substance in small quantity, which, examined by the microscope, proved to be pus 



600 LOCAL DISEASES. 

the largest amount being near the pons Varolii. There was no tubercle under the 
meninges or elsewhere, and no appreciable fibrinous exudation. The meningitis, 
though of brief duration, was nearly general. The only additional lesions noted 
were moderate congestion of the brain and an increase in the quantity of the cerebro- 
spinal fluid. 

If the disease be protracted three or four weeks, which is rare, or even less 
time, the exuded substance may undergo further changes, such as occur in simple 
exudations in other parts of the system. Thus, on the 30th of April, 1860, we 
made the post-mortem examination of an infant at the Nursery and Child's Hos- 
pital who had symptoms of cerebral disease, it was stated, for several weeks, but 
the exact time was not ascertained. Prominent among the symptoms referable to 
the cerebro-spinal system toward the close of life were the hydrocephalic cry and 
rigidity of the neck. The appearance at the autopsy was remarkable. The ante- 
rior half of the brain was completely encased in a deposit which had nearly the 
appearance of lard. It filled the fissures of Sylvius and appeared slightly on the 
anterior aspect of the cerebellum. Examined under the microscope, this substance 
was found to contain numerous cells, among which could be distinguished some 
resembling pus-cells, but nearly all had undergone more or less fatty degeneration. 
Here and there was seen a large cell containing numerous small oil-globules, the 
compound granular cell of pathologists. 

The brain itself in meningitis is usually hyperaemic. On making an in- 
cision through it red points are seen upon the cut surface, which indicate the 
seat of the congested vessels. The inflammation rarely extends to the walls 
of the ventricles, but the choroid plexus is injected. In exceptional in- 
stances pus or fibrin is found in the lateral ventricles. In the infant two 
and a half weeks old whose case has already been alluded to about two 
ounces of purulent fluid escaped on opening the left ventricle. A small 
amount of liquid of a similar character was contained in the right ventricle. 
The distention of the lateral ventricles with serum is one of the common 
results of meningitis. This fluid is clear or straw-colored, or it is turbid. 
The quantity does not exceed two, three, or four ounces, and is often not 
more than one ounce or an ounce and a half. The distention of the two 
ventricles is ordinarily uniform, as they are united by the foramen of Monro, 
but now and then one ventricle is found more distended than the other. If 
there be considerable effusion, the brain is compressed and the convolutions 
have a flattened appearance, unless the cranial bones are still separated so as 
to yield to the pressure. If the sutures and fontanelles be open, the cranial 
arch is expanded, sometimes quite perceptibly to the eye. From the same 
cause the anterior fontanelle, if open, is elevated. The foramen of Monro 
is enlarged according to the amount of effusion, and the portions of the brain 
which separate the ventricles are sometimes lacerated. In many cases the 
cerebral substance surrounding the lateral ventricles is softened. The soft- 
ening is found in all degrees, from the least appreciable deviation from the 
normal consistence to a state of difnuence, so that the brain-substance pre- 
sents the appearance of cream. Hypotheses have been advanced to explain 
the cause of this change in consistence which are not entirely satisfactory. 
Whatever the explanation, the fact is attested by all observers, though there 
are exceptional cases. Thus Dr. West has records of the condition of the 
brain in 59 cases, in 37 of which there was considerable softening, and in 
the remaining 22 the consistence was normal. 

Since a majority of the cases of meningitis in children are basilar, and 
portions of all the cerebral nerves lie at the base of the brain, it is easy to 
understand why the functions of these nerves are so seriously impaired in 
this malady. Compression of these nerves or extension of inflammation to 
their sheaths affords explanation of many of the symptoms, as the sighing 
respiration, abnormalities of the eye, etc. 

Although the above remarks relating: to the anatomical characters of 



3IENINGITIS. 601 

meningitis are applicable to a large majority of the cases, sometimes at the 
autopsies of young infants who died with all the symptoms of meningitis, 
the phvsieian is surprised in not finding more lesions. Moderate hyperaemia 
of the pia mater, slight opacity or cloudiness at the base of the brain or 
elsewhere, with the presence of a few wandering white corpuscles, without any 
fibrinous exudation, with no increase of liquid external to the brain, but a 
considerable increase of it in the lateral ventricles, and hyperaemia of the 
choroid plexus, with nearly natural appearance and consistence of the brain, 
have in some instances been the only lesions when I had expected to find 
marked anatomical changes. 

I am fully convinced from my observations that in some instances physi- 
cians who supposed that they were treating tubercular meningitis, and at 
the autopsies discovered within the cranium tubercles, without any inflam- 
matory lesion, but with an increase of the cerebro-spinal liquid, have been 
treating cases in which, in addition to the meningeal tubercles which were 
latent, the bronchial glands were tubercular and cheesy, so that by their 
increased size they compressed the venae innominatae within the thorax, thus 
preventing the free flow of blood from the brain, and causing, as I have 
elsewhere stated, cerebral and meningeal congestion, with more or less trans- 
udation of serum, but with no meningitis. In tubercular meningitis the 
anatomical characters are like those in simple meningitis, with the addition 
of tubercles, which at first are minute and transparent, and are most easily 
detected when the inflammation has been slight. Located in the pia mater, 
they cause some prominence of the arachnoid, and are best seen when so 
minute by an oblique light. 

Causes. — The causes of non-tubercular meningitis are not fully ascer- 
tained. Active cerebral congestion frequently occurring, however produced, 
appears to be one of the common causes in young infants. In at least three 
instances I have known meningitis to occur in infants between the ages of 
four and eight months after severe and protracted bronchitis, which had 
been attended with the usual heat of head. This disappearance of eruption 
upon the scalp at or immediately before the commencement of the menin- 
gitis has also been observed. I have witnessed it at the commencement of 
non -tubercular meningitis, as well as of meningitis which, if not tubercular, 
occurred at least in a decidedly scrofulous state of system. 

The direct effect of the solar rays upon the head and the prolonged action 
of a high atmospheric temperature are believed to be an occasional cause of 
meningitis. I once attended a child with this disease who had been much 
exposed bareheaded to the direct rays of the sun in August and Septem- 
ber, and at his death, which occurred toward the close of the hot weather, 
found hyperaemia, opacity, and fibrinous exudation in the pia mater at the 
summit of the brain, while the base of the brain seemed nearly or quite 
normal. 

Dr. Soltmann * of Breslau reports three cases in which intense cerebral 
hyperaemia, and probably meningitis, occurred from solar heat. In all three 
children the attack was sudden, the febrile movement and heat of head in- 
tense, and the progress rapid. The first had convulsions, the second auto- 
matic movements, and the third, the oldest, aged four years, when able to 
speak complained of violent headache. 

The statistics of New York City show that congestive and inflammatory 
maladies of the brain and its covering are more common during July and 
August, which are the months of maximum atmospheric heat, than in other 
months of the year. For example, in July and August, 1875, 167 died of 
these maladies, or 1 in every 9.8 who died from local disease, while during 
1 Jahrbuchf. Kinderkrank., for October, 1875. 



602 LOCAL DISEASES. 

the entire year only 710 died from the same, or 1 in every 15 who perished 
from local diseases. 

July, 1876, in New York City was characterized by excessive and long- 
continued atmospheric heat, the temperature of the Central Park Observatory 
in the shade never falling below 61°, though never above 98°, and having a 
mean of 82.9°. There was also unusual dryness of the atmosphere, since 
during the entire month prior to July 30th there were only fourteen hours 
of rain with a rainfall of 0.77 of an inch, and the average atmospheric 
humidity was represented by 65, saturation being denoted by 100. During 
this month I treated in my private practice four fatal cases all between the 
ages of two and seven years, which I diagnosticated meningitis, none of them 
presenting any symptoms of otitis or tuberculosis. It would seem that the 
atmospheric heat had much to do with the development of the disease in 
these cases. One died in two days, but in the others there was the usual 
duration. Gowers also mentions insolation among the occasional causes. 

A not infrequent cause, especially among the strumous families of cities, 
is otitis media and caries of the petrous portion of the temporal bone, the 
inflammation extending to the meninges. Any suppurative inflammation 
occurring outside the dura mater, but in immediate proximity with it, may 
by extension cause meningitis ; but the most common cause of this kind is 
purulent otitis. The external discharge of pus from the ear usually ceases 
when the meningitis begins. Gowers states that several cases are on record 
of meningitis occurring from traumatic inflammation of the eye, the inflam- 
mation probably passing along the sheath of the optic nerve. He also states 
that the following acute diseases occasionally sustain a causal relation to 
meningitis : measles, scarlet fever, smallpox, typhoid fever, pneumonia, and 
acute rheumatism. But the meningitis occurring with or from pneumonia 
is probably cerebro-spinal fever, and meningitis occurring from the acute 
infectious diseases mentioned by Gowers is certainly rare, and perhaps its 
coexistence with them is in at least some instances a coincidence. Septic 
processes in any part of the system occasionally cause meningitis from 
microbes, which, entering the circulation, are conveyed to the meninges. 
Since tubercular meningitis is due to the irritating effect of tubercles in or 
under the pia mater, it usually occurs where tubercles are most abundantly 
developed ; that is, at the base of the brain and along the course of the 
vessels in the intergyral spaces. The inflammation is commonly excited 
when they are still small, even minute. 

Premonitory Stage. — Meningitis is usually preceded by symptoms 
which, if rightly interpreted, are of the greatest value. In most cases of 
this malady which I have seen there was a prodromic period varying from 
a few days to several weeks. The symptoms of this period are obscure, and 
are liable to be mistaken for those of other and distinct affections. 

The child in whom meningitis is approaching loses his accustomed 
vivacity and cheerfulness. He has a melancholy and subdued appearance, 
being quiet a few minutes, and then fretful, without apparent cause. He 
can sometimes be amused by his playthings or companions for a brief period, 
when he turns from them with evident displeasure. Unexpected and loud 
noises and bright lights are evidently painful. If old enough to describe his 
sensations, he complains of transient dizziness, and at other times of head- 
ache. His ill-humor, if his wishes are not immediately gratified or if they 
are denied, is often scarcely endurable on the part of friends who are ignorant 
of the cause. There is great difference, however, in different cases as regards 
this symptom. Some are inclined to be taciturn and quiet, while others are 
almost constantly fretting. The appetite is capricious ; at one time it is 
pretty good, at another it is poor or even entirely lost. The patient may 



MENINGITIS. 603 

take a few mouthfuls of food, or. if an infant, may nurse a moment, when his 
hunger appears satisfied and he will take nothing more. The bowels are 
regular or inclined to constipation. The pulse is natural or it has times 
of acceleration, especially in the latter part of the day and toward the close 
of the premonitory stage. The duration of this stage is very different in 
different cases. Upon an average it is perhaps about two weeks, but it is 
often longer. In tubercular meningitis the symptoms, both during the 
inflammation and previously, are often complicated by those which arise 
from . tubercles in other parts of the system. Of the symptoms premonitory 
of the disease and present in its first stages, headache and vomiting are 
especially prominent. 

Unless the prodromic period be of short duration the effect of imperfect 
nutrition is obvious before it closes. The flesh becomes soft and flabby or 
there is emaciation, though generally slight. The patient loses his strength, 
becoming less able to stand or to walk, and more easily fatigued. Occasion- 
ally, especially in the non-tubercular form, premonitory symptoms are absent 
or are slight and of short duration. 

Symptoms. — Dr. Whytt, living in the last century, when the tendency 
was toward refinement rather than simplicity in classification, divided menin- 
gitis into three stages, according to the symptoms, especially the pulse. 
3Iany subsequent writers, following Whytt's example, have recognized three 
stages, based not upon the anatomical characters of the disease, but upon the 
succession of symptoms. Such division of meningitis is in great measure 
arbitrary, since in one case the same symptoms occur at an earlier period 
than in another. 

When the premonitory stage has passed and inflammation is developed, 
some of the symptoms which were previously present remain and are inten- 
sified, and other new and more characteristic symptoms appear. There are 
fewer intervals of apparent improvement. The child is quiet, often lying 
with his eyes shut. If aroused he has a wild expression of the face, and is 
irritated by attempts to engage his attention or amuse him. He rarely 
smiles or takes his playthings, or he notices them for a moment, when he 
turns away with disgust. During sleep there is often at first a placid expres- 
sion of countenance, but when aroused he has the aspect of real sickness ; 
the eyebrows are sometimes contracted, as if from headache ; the features 
wear a melancholy look, and are turned away to avoid the gaze of the 
observer or to shun the light. If the anterior fontanelle be open, it is 
observed to be prominent and pulsating forcibly. If consciousness be not 
lost and the patient be of sufficient age, he complains of headache or of pain 
in some part of the body. The tongue is moist and covered with a light fur ; 
the appetite is lost or poor ; there is seldom much thirst ; more or less nausea 
and constipation are present. As the inflammation continues, and usually 
within three or four days from its commencement, symptoms arise which 
dispel all doubts, if there were any, as to the nature of the disease. The vital 
powers are now evidently beginning to yield. The surface generally is more 
pallid, and there is the curious phenomenon of the sudden appearance — and 
after some minutes disappearance — of spots or patches, or even streaks, of 
active congestion upon the face, forehead, or ears. These, having a bright- 
red color, contrast strongly with the general pallor. Ordinarily they are 
irregularly circular or oval, and from one inch to an inch and a half in 
diameter. A red spot or streak is also produced if the finger be pressed 
upon the surface or drawn forcibly across it. It continues a few minutes. 
and then gradually fades. Trousseau calls attention to this met as a diag- 
nostic sign. It is known as the tdche cerebrate of Trousseau, and it affords 
some aid in diagnosis, but the tdche cerebrale is common in some other diseases. 



604 LOCAL DISEASES. 

Another curious phenomenon is the variation in temperature. The face 
and limbs at one time feel quite cool, and after some minutes, without any 
excitement or other appreciable cause, the temperature rises, so that the sur- 
face is warm to the touch. 

Consciousness in severe cases may be lost at an early period. On the 
other hand, I have known it in a case of moderate severity to remain, though 
partially obscured, till within twenty-four or thirty-six hours of death. The 
patient will usually open his mouth for drinks which are placed to his lips 
when there is no other evidence of intelligence and when sight and hearing 
are evidently lost. 

The loss of the senses constitutes an interesting but melancholy feature 
of the disease. Among the first unequivocal signs, and frequently the very 
first, are such as pertain to the eye. This organ should be watched from day 
to day when the diagnosis is uncertain. Deviation from its normal state 
affords evidence of meningitis. The pupils are seen to dilate or contract 
sluggishly by variations in the intensity of the light, or they are not of the 
same size with those of another individual to whom the same amount of 
light is admitted. Sometimes the first perceptible deviation from the normal 
state is an inequality in the size of the pupils, while in others oscillation of 
the iris is observed. Later, when convulsions have occurred, the parallelism 
of the eyes is lost. After effusion has taken place the pupils are commonly 
dilated. As death approaches the eyes become bleared and a puriform secre- 
tion collects in the inner angle of the eye and between the eyelids. This 
secretion is not abundant, but it is sometimes sufficient to unite the lids. 
The sense of hearing is probably lost as soon, or nearly as soon, as that of 
sight, but the sense of touch continues longer. The tongue is covered with 
a moist fur, unless near the close of life, when it is sometimes dry. The 
appetite is gradually lost, but often drinks are taken with apparent relish, 
even when there is no other evidence of consciousness. There are two symp- 
toms pertaining to the digestive system which are rarely absent, and which 
possess great diagnostic value : one is vomiting, the other constipation. In 
some patients irritability of stomach begins at so early a period that it is 
really prodromic ; it is rarely absent. Barrier collected the records of 80 
patients with meningitis, and in 75 of these this symptom was present. It 
is due to the intimate relation existing between the stomach and brain 
through the ganglionic system of nerves. The vomiting occurs without 
effort, and usually at intervals for several days. It is a sudden ejection of 
the contents of the stomach, apparently without preceding or subsequent 
nausea. It contrasts, therefore, with the vomiting due to an emetic, which 
is attended by distressing symptoms. With some it occurs frequently, with 
others not more than two or three times daily. Commencing in the first 
stages of meningitis or even prior to it, it occurs less often as the drowsiness 
becomes more profound, and finally ceases. Constipation is also present, 
usually from the commencement of the meningitis. It is one of the most 
constant and persistent symptoms, continuing throughout the entire sickness, 
unless relieved by medicine or unless there be a coexisting diarrhceal affec- 
tion. Often, when diarrhoea precedes the meningitis, it ceases the moment 
the latter commences. The constipation in this disease is easily overcome by 
purgatives. Several writers speak of retraction of the abdomen as a sign of 
meningitis. A hollow or sunken appearance of the abdomen, according to 
Golis, aids in distinguishing meningitis from fever. The anterior abdominal 
wall approaches the spine, so that the pulsations of the abdominal aorta are 
distinctly felt. Rilliet and Barthez. who have rarely observed this retrac- 
tion except in cerebral diseases, attribute it to the state of the intestines 
rather than to the action of the abdominal muscles. 



MENINGITIS. 605 

The pulse in the first stages of meningitis is accelerated, or it is nearly 
natural during certain hours and afterward accelerated. When the disease 
has continued a few days, often not more than three or four, the pulse under- 
goes a marked change. It becomes slower and at the same time irregular. 
The irregularity usually consists in an intermittence of the pulse after each 
six or eight beats. Sometimes the force of the pulse varies, so that a feeble 
pulsation is succeeded by one of greater volume and strength. The decrease 
in the frequency of the pulse cannot fail to arrest attention. From 110 or 
120 beats per minute in the first stage of the inflammation it often descends 
to a frequency even less than that of the normal adult pulse. At an ad- 
vanced period, as death approaches, the pulse again becomes accelerated 
and feeble. 

The change in respiration is as marked as that of the pulse. In the 
beginning of meningitis the breathing is in some patients moderately accel- 
erated ; in others it is natural. When the disease has continued a few days, 
the time usually varying from three or four days to more than a week, a 
marked alteration occurs in the respiratory movements. Their rhythm, like 
that of the pulse, is changed. The breathing is irregular, intermittent, and 
accompanied by sighs. The change in pulse and respiration corresponds 
with the loss of consciousness, and shows that the brain is becoming seriously 
involved. 

When the pulse and respiration undergo the changes which have been 
described, another prominent and grave cerebral symptom is sometimes pres- 
ent — to wit, convulsions. Their occurrence diminishes greatly the prospect 
of a favorable issue. The severity and extent of the convulsive movements 
vary in different cases. They may be partial or general. Their duration is 
often brief, but they recur three or four times through the day. They are 
preceded by cephalalgia in those old enough to express their sensations, 
and often by drowsiness. Each convulsive attack ends in still greater 
drowsiness. 

With this group of symptoms another should be mentioned. I refer to 
the hydrocephalic cry. At intervals the patient, without being disturbed 
and without any change in symptoms, utters a scream or sharp cry, and 
immediately relapses into his former state. This cry is more common in the 
commencement of the meningitis than subsequently, and in many it is absent 
or is not a marked symptom. The glandular system participates in the gen- 
eral loss or derangement of function. Tears are seldom shed even when the 
child is much irritated, and the urinary secretion is diminished. The small 
amount of urine passed sustains an important relation to the progress of the 
disease and the therapeutics. 

The patient usually lingers several days after the pulse and respiration 
are changed in the manner stated. The drowsiness becomes more profound, 
the vomiting ceases as well as the convulsive attacks, and sensation and con- 
sciousness are entirely lost. But even in this state, if nutriment and stimu- 
lants be administered with regularity, the child often lives several days 
longer than appeared possible. At length increasing feebleness and rapidity 
of pulse and coldness of the face and limbs indicate the near approach of 
death, which occurs in a state of coma. 

The symptoms described above are such as we observe in ordinary cases 
of meningitis, and in the order which I have indicated, but this description 
does not apply to all cases. 

Meningitis may be so violent and rapid that both the character and suc- 
cession of symptoms are different from those which have been stated. Thus, 
I have related the case of a girl who, with no prodromic symptoms excepting 
occasional dizziness and slisrht headache, was taken sick on Thursday, had 



606 LOCAL DISEASES. 

convulsions on Friday, and from this time continued either in convulsions or 
coma till her death on Monday. Again, even in cases of the usual duration 
and anatomical character some of the most prominent symptoms upon which 
we rely for diagnosis may be lacking. The following was a case of this 
kind : 

Case. — On the 5th of April, 1862, 1 was asked to see a boy, two years and eight 
months old. of healthy parentage, who during the preceding year had been in uni- 
form good health, but previously had had two or three severe attacks of sickness. 
His head was unusually large, and whenever much indisposed he often had symp- 
toms premonitory of convulsions, which were always, however, prevented. 

One night in the latter part of March his parents noticed that his sleep was 
restless, but on the following day he seemed entirely well, and the restlessness at 
night was attributed to a late and hearty supper. On succeeding nights, however, 
he was restless, and when questioned complained of pain in the abdomen. In a few 
days he was observed to be drooping in the daytime, and his appetite was not quite 
so good as previously. He had continued in this way about a week when my first 
visit was made. 

The abdominal pain had at this time become more constant, but was never 
severe or accompanied by moaning. When asked where he felt sick, he placed his 
hand upon the epigastrium, pressure upon which was sometimes tolerated, but at 
other times painful. The following symptoms were noted: tongue slightly furred, 
anorexia, thirst, constipation, scantiness of urine, no headache or unusual heat of 
head during any part of his sickness. He vomited at intervals from about the 7th 
to the 10th of April, when the irritability of stomach ceased and there was no return 
of this symptom. 

About April 7th the respiration was first observed to be irregular and sighing, 
and the pulse intermittent. These symptoms, so tardily developed, were the first 
which indicated cerebral disease. He now lay most of the time in bed with eyes 
closed, surface commonly pallid, with occasional rose-colored spots or patches upon 
the cheek or forehead. The pupils responded to light in the usual manner till near 
the close of life, but bright lights were painful : the last two or three days of his 
life the left pupil was more dilated than the right. He had no convulsions or any 
spasmodic movement, and was conscious till within a few hours of death : the 
mother states that there was unequivocal evidence of his recognition of her on the 
last day of his life. He died April 17th, nearly three weeks after the commencement 
of the disease and ten days after the commencement of symptoms which were clearly 
referable to the brain. 

Autopsy. — Abdominal organs healthy, though epigastric pain had been so con- 
stant and prominent a symptom ; brain and its membrane somewhat injected. The 
meninges covering the base of the brain from the most prominent part of the pons 
Varolii to the first pair of nerves presented evidences of inflammation. There was 
such opacity of the pia mater in places as to conceal the brain from view. The ante- 
rior and middle lobes of each hemisphere were glued together by fibrinous exuda- 
tion, and on the left side, along the fissure of Sylvius, was a thick deposit of the same 
character. The lateral ventricles contained about an ounce of clear serum, and about 
half an ounce escaped from the base of the brain. The foramen of Monro was con- 
siderably enlarged, and the brain-substance surrounding the lateral ventricles was 
softened. 

In this case it is seen that the prominent symptom — and, indeed, almost 
the only marked symptom in the first stages of the disease — was pain in the 
abdomen, and yet the abdominal organs were healthy. At the very moment 
when it was highly important that a correct diagnosis should be made, the 
evidences of cerebral disease were lacking. This case is therefore interesting 
on account of the variation in symptoms from those in the usual form of 
meningitis. There were no convulsions, and consciousness was retained, as 
well as vision, till near the close of life, and yet the lesions were such as are 
commonly present in meningeal inflammation. It is in such cases that a 
wrong diagnosis is frequently made, to the injury of the patient and the 
reputation of the physician. 



MENINGITIS. 607 

Occasionally meningitis may continue so long as almost to justify its 
"being called chronic, even when there is a large amount of exudation upon 
the pia mater. In the few cases which end favorably the symptoms 
abate gradually. I shall describe more fully the termination in speaking of 
Prognosis. 

Diagnosis. — It is of the utmost importance to diagnosticate meningitis 
in its first stages, since treatment to be successful must be commenced early. 
Certain writers describe at length the means of diagnosticating the simple 
from the tubercular form of the inflammation. Differential diagnosis is often 
difficult, and sometimes impossible ; but it matters little, practically, whether 
the form of the disease be ascertained. On the other hand, it is very im- 
portant, in order that the treatment be appropriate, to diagnosticate the pre- 
monitory or initial stage of meningitis from certain other affections not located 
within the cranium. Sometimes remittent or continued fever or constitu- 
tional disturbances arising from irritation in the digestive system simulate 
closely incipient meningeal disease, so that the greatest care and discrimi- 
nation are required in order to make a correct diagnosis. Within a compara- 
tively recent period I have known in three different instances experienced 
physicians of this city to mistake commencing meningitis for fevers, not 
aware of the serious error they had made till the inflammation had reached a 
stage from which recovery was impossible. In order to avoid error in the 
diagnosis in the premonitory or initial stage of meningitis, the physician 
should take time to observe the physiognomy and note every symptom. 
More than one protracted visit is often required to remove doubt as to the 
exact pathological state. 

Meningitis is usually preceded, and in its commencement accompanied, 
by greater restlessness, fretfulness, intolerance of light, and a greater varia- 
tion of symptoms, than most other maladies. One familiar with the physiog- 
nomy of infancy and childhood will discover in the features indication of 
greater suffering, of more serious sickness, than is commonly present in other 
maladies which simulate this. The eye should always be carefully observed. 
Inequality of the pupils, their oscillation, strabismus, nystagmus, and espe- 
cially the altered state of the optic disks, which a distinguished oculist has 
designated " outlying portions of the brain, ' ; will often assist in making the 
diagnosis positive. 

Sometimes the sudden disappearance of a chronic eruption upon the scalp 
will aid in the diagnosis. This is a sign of importance, taken in connection 
with the symptoms. Headache and vomiting, symptoms of early occurrence, 
should especially arrest attention, or in absence of headache, pain of a neur- 
algic character in some other part. But we may repeat that familiarity 
with the symptoms of meningitis will not protect from error, if the visits of 
the physician are hasty and his examinations imperfect. When the eyes 
become affected, the respiration and circulation irregular, and especially when 
convulsive attacks begin, diagnosis is easy. In fact, an incorrect diagnosis 
would then be unpardonable ; but, unfortunately, if proper treatment have 
not been commenced till this period it will be of little service. 

Prognosis. — Meningitis is one of the most fatal maladies of early life. 
Whether the form be tubercular or not, if the initial stage have passed with- 
out proper treatment, death may be considered inevitable. Tubercular men- 
ingitis, however early recognized, is rarely amenable to treatment. M. Guer- 
sant x believes that recovery from the first stage of this form of meningitis 
is possible. " In the second stage," says he, " I have not seen one child 
recover out of a hundred, and even those who seemed to have recovered 
have either sunk afterward under a return of the same disease in its acute 
1 Diet, mid., t. xix. p. 403. 



608 LOCAL DISEASES. 

form or have died of phthisis. As to patients in whom the disease has 
reached its third stage, I have never seen them improve even for a moment. " 
The very few reported cases which resulted favorably may have been, as M. 
Guersant has intimated in the context, cases of the non-tubercular form. 
Rilliet and Barthez believe that in a few instances tubercular meningitis 
has been cured in its first stage, but they state also that it is likely to 
return. 

The PROGNOSIS in non-tubercular meningitis is not so unfavorable, provided 
that treatment be commenced at a sufficiently early period. It is now gen- 
erally admitted that it may not infrequently be averted when threatening, 
and even arrested in its incipiency. In many such cases we cannot, from the 
nature of the disease, be certain that the diagnosis is correct. But when we 
see children relieved who present precisely those premonitory and even initial 
symptoms which occur in meningitis, we must believe that at least some of 
them would have had the genuine disease if not relieved by the measures 
employed. That in its commencement recovery is possible is also obvious 
from the fact that a few recover even in the second stage, when there can be 
no error of diagnosis. 

Although a considerable proportion of patients with epidemic cerebro- 
spinal meningitis recover, even when the symptoms have been most grave, 
I have known only two recoveries from sporadic meningitis when it had 
reached that stage in which the functions of the brain and cranial nerves 
were impaired. One of these recovered with permanent loss of sight, the 
other with loss of hearing. Both seem to have ordinary intelligence. An- 
other case has been communicated to me in which the patient, a little child, 
recovered completely, but for several months after the attack seemed nearly 
idiotic. 

Sometimes, even in the second stage of meningitis, treatment properly 
employed is attended by amelioration of symptoms. Though such improve- 
ment may serve to encourage physician and friends, it should not be the basis 
for a favorable prognosis unless it continue three or four days. 

Apparent improvement during a few hours or a considerable part of a 
day is not unusual in those who finally die. Thus, in an infant whose bowels 
were previously confined I have known the pulse and respiration to become 
more regular and the symptoms generally improve, though only for a brief 
period, by the action of a purgative. Dr. Watson says of the advanced stage 
of this disease, it is " often attended with remissions, sometimes sudden and 
sometimes gradual — deceitful appearances of convalescence. The child re- 
gains the use of its senses, recognizes those about it again, appears to its 
anxious parents to be recovering, but in a day or two it relapses into a state 
of deeper coma than before. And these fallacious symptoms of improvement 
may occur more than once." 

Most fatal cases of meningitis terminate between the third or fourth and 
the twentieth day, the duration varying according to the extent and intensity 
of the inflammation and the vigor and age of the patient. But there are 
cases in which it may continue much longer. It is surprising sometimes 
how long the patient lives when the symptoms are such that death seems 
impending. Sensation and consciousness may be extinguished, convulsions 
occur at intervals, and the surface have acquired almost a cadaveric aspect. 
and yet the patient lives on. Rilliet and Barthez say : " Often have we 
inscribed upon our notes death imminent, and been astonished the next day 
to find still alive children to whom we had scarcely allowed two hours of 
life." The symptom which I have found to be the most reliable prognostic 
of the near approach of death has been a pulse gradually becoming more 
frequent and feeble, though other symptoms remain as before. This change 



MENINGITIS. 609 

in the pulse is usually very apparent during the last twenty-four hours of 
life. 

Treatment. — Such remedial measures should be prescribed during the 
premonitory stage as are calculated to relieve the fretfulness or irritability of 
temper and quiet the action of the brain, and at the same time produce a 
derivative effect from this organ. To this end the patient should be kept 
from all causes of excitement, and the bowels should be opened daily — if not 
naturally, by the use of proper medicines. A mustard foot-bath at night and 
occasionally through the day is useful, as it produces both a derivative and 
soothing effect. It will commonly produce a few hours' undisturbed rest, 
while other measures except medicines fail. If dentition be taking place and 
the gums are swollen, it has been the practice to employ the gum-lancet, 
and still is with some physicians, but I for one have discarded its use for 
this purpose. Restlessness from dentition or restlessness premonitory of 
meningitis requires large doses of bromide of potassium, which will relieve 
the symptoms more effectually than the lancet. Three grains should be 
given to a child of six months, and four grains to one of ten or twelve 
months, and repeated if necessary in one to two hours. If symptoms indi- 
cate the near approach of meningitis or its incipiency, the head should be 
kept constantly cool by a cloth wrung out of ice-water, or, better, an India- 
rubber bag containing ice. Some physicians have recommended vesication 
back of the neck or ears, but it is a measure of doubtful benefit, and if em- 
ployed at all should be restricted to the application of cantharidal collodion 
behind the ears. All purulent collections near the meninges should be 
opened and disinfected, and especially should the ear be examined, and if 
the membrana tympani be bulging or hypersemic, paracentesis should be 
performed, and followed by washing with a warm and weak solution of 
boracic acid. 

Many children who are threatened with meningitis are scrofulous. They 
have already shown symptoms of tubercular disease. They are perhaps, to 
a certain extent, emaciated, and may have been affected with a cough. If 
the premonitory symptoms in children indicate the approach of the tuber- 
cular form of meningitis, a more sustaining course of treatment is required 
than in those who are robust. To such children cod-liver oil may be profit- 
ably given three times daily, together with the syrup of the iodide of iron, 
and perhaps the bromide. They should also be taken into the open air with 
proper precautions, and every hygienic measure should be employed which 
will be likely to invigorate the system without exciting the brain. 

Loss of blood is not, in general, required during the prodromic period nor 
in the disease. Those of a strumous cachexia, or those, whether strumous or 
not, who are under the age of two years, do not, unless in very rare instances, 
require depletion by leeches, much less by venesection. There is one class 
of patients in whom the early loss of blood may perhaps be of service — 
namely, those who in a state of robust health are suddenly seized with 
inflammation, especially if the cause be insolation. Leeches may then be 
applied to the head of the patient if he be seen at an early period, but the 
majority of physicians probably wisely recommend the ice-bag in preference 
to leeching. 

Often, notwithstanding the measures employed, the patient grows worse ; 
the symptoms become more continuous, others more alarming arise, and 
meningitis declares itself. Whatever the cause of the inflammation, and 
whatever modifications of treatment were required in the premonitory stage 
on account of special indications, the purpose now is to subdue the inflam- 
mation by every resource in our art which does not injure or too much pros- 
trate the system. In former days calomel was largely employed as the main 



610 LOCAL DISEASES. 

remedy in this disease, but when administered daily it has a very depressing 
effect, and it is to be borne in mind that in meningitis the vital powers pro- 
gressively fail on account of the loss of appetite, vomiting, etc. In tuber- 
cular meningitis depressing treatment is of course strongly contraindicated. 
.Cases have occurred in which calomel was given at short intervals for 
several successive days, so as to produce a laxative effect, but. though the 
meningitis seemed to be controlled, death resulted from exhaustion or from 
some intercurrent affection due to exhaustion. Thus in one case formerly 
related to his class by a distinguished New York professor, fatal gangrene of 
the mouth supervened from the mercurial treatment after the meningeal 
inflammation had apparently subsided. Although calomel during these last 
years has been properly discarded as the main remedy and its daily use 
rejected, nevertheless it is very useful as an occasional laxative in the more 
robust cases if not given too near the iodide of potassium ; and it is especially 
indicated as a derivative from the head in children of four or five years, who, 
previously hearty and strong, have become suddenly affected with meningitis, 
as from exposure to the sun's rays or from an injury. But I repeat the 
belief that in ordinary cases calomel should never be employed, except as 
an occasional laxative. 

The two remedies upon which we must chiefly rely are the iodide of 
potassium and the bromide of potassium or sodium. While the bromide 
quiets the restlessness, prevents convulsions, and diminishes, there is reason 
to think, to a certain extent, the hyperemia, the iodide is useful as a sorbe- 
facient, and it probably has some control over the inflammation. The iodide 
or bromide can be given together or separately. 

The iodide should, like the bromide, be given early. If by a careful 
examination the absence of any other local disease or constitutional disease 
which might give rise to the symptoms be ascertained, and the symptoms 
indicate the meningeal disease, the iodide should be immediately prescribed. 
Obscurity often hangs over meningitis at this early stage, but it is better to 
give the iodide, even if the diagnosis be wrong and no inflammation have 
commenced, than to err on the other side, and withhold it in the initial period 
of the true disease ; for it is not an injurious remedy like calomel, and to 
exert any marked effect it should be given in the commencement of the 
inflammation. An infant of the age of six to twelve months should take two 
grains every two hours, and older children a proportionate dose. At the same 
time the bromide should be given in doses twice as large as that of the iodide 
if the indications for its use are present — to wit, headache, restlessness, and 
symptoms which threaten eclampsia. The bromide is a harmless remedy 
given frequently for a limited time. With the regular and continued use 
of the iodide and occasional doses of bromide, the quantity of urine is in 
most cases largely increased. If the patient's condition do not soon begin 
to improve with such treatment, there is no remedy. 

If convulsions occur, the bromide should be given every ten or fifteen 
minutes till they cease. If they be not controlled by the bromide, an injec- 
tion, per rectum, of three to five grains of hydrate of chloral in a teaspoonful 
of water should be used in addition. Compresses wrung out of ice-water fre- 
quently applied to the head, or a bladder containing pounded ice and separated 
by one thickness of muslin from the head, materially aid in reducing the 
meningeal hyperaemia. Ergot, recommended by Brown-Sequard for its sup- 
posed effect in diminishing the hyperaemia in the inflammatory diseases of the 
nervous centres, may also be employed as an adjuvant in the treatment of this 
disease, but it has much less effect upon the hyperaemia of the brain or 
meninges than upon that of the uterine system. 

In the first stage of simple meningitis the diet should be mild and in 



SPUMOUS HYDROCEPHALUS. 611 

moderate quantity, but in the tubercular form it should from the first be 
of the most nourishing kind, consisting of beef tea, milk porridge, etc. At a 
more advanced stage in both forms of the malady the most nutritious diet 
should be allowed, but alcoholic stimulants should not be given unless near 
the close of life, when the vital powers are failing. The apartment should be 
cool and quiet. 



CHAPTEE VI. 

SPURIOUS HYDROCEPHALUS. 

The disease known as spurious hydrocephalus might with more propriety 
be called spurious meningitis. It received its appellation at the time when 
meningitis of early life was believed to be essentially a hydrocephalus, and 
was so called. Attention was first directed to it by London physicians of the 
last generation, particularly by Drs. Grooch, Abercrombie, and Marshall Hall, 
and little can be added to their description of its symptoms. 

Anatomical Characters. — This disease, though resembling meningitis 
in certain of its phenomena, is not in its nature inflammatory, nor is it 
primary. It is the result of some malady often chronic, but occasionally 
acute, which has produced exhaustion, especially of the nervous system. 
When it commences there is usually more or less emaciation and the symp- 
toms of the primary disease are present. To this disease the lesions pertain 
which are found in other organs besides the brain. 

The state of the brain in spurious hydrocephalus is not the same in all 
cases. In some there is no appreciable anatomical alteration in this organ. 
There is no apparent difference, either in the meninges or the brain itself, 
from the condition which we often observe in those who have died of diseases 
which do not affect the cerebro-spinal system. In such cases the pathological 
state is simply deficient innervation, or if there be a structural change in the 
minute anatomy of the brain, pathologists have not yet discovered it. 

The following case, which occurred in the Child's Hospital of this city, is 
an example of this form of spurious hydrocephalus : 

Case. — A female infant, six months old, died on the 24th day of April, 1862, 
with the following history : It was wet-nursed, fleshy, and apparently well till six 
days before death, when symptoms of gastro-intestinal inflammation were suddenly 
developed. The vomiting especially was severe, continuing forty-eight hours. When 
it ceased, drowsiness supervened and continued till the close of life. The face during 
the four days of stupor was pallid and cool ; eyes partly open, pupils sluggish, but 
of equal size ; bowels rather torpid ; anterior fontanelle depressed. When aroused 
the infant noticed objects for a moment, and immediately relapsed into sleep ; pulse 
accelerated and not intermittent, the day before death numbering 150; respiration 
accelerated, without sighing, numbering on the same day 30. There were no con- 
vulsions, and death occurred quietly. The brain weighed twenty and a half ounces, 
and its appearance was perfectly healthy, both as regards consistence and vascu- 
larity. The amount of cerebro-spinal fluid in the ventricles and at the base of the 
brain was not notably increased. The stomach, small and large intestines, were 
vascular in streaks and patches. 

In this case the cerebral symptoms were obviously due to exhaustion 
occurring at an early period in consequence of the severity of the gastro- 
intestinal malady. 



612 LOCAL DISEASES. 

In a majority of cases, however, of spurious hydrocephalus, according to 
my observation, there is an anatomical alteration in the state of the brain and 
meninges. This consists in passive congestion of the veins, often with tran- 
sudation of serum. At the same time, the cranial sinuses are congested, and 
are found at the post-mortem examination to contain larger and more numer- 
ous clots than are present in those who die of diseases which do not affect 
the encephalon. Cases might be cited as examples. The cause of this con- 
gestion and effusion is in a great measure feebleness of the circulation due to 
the general exhaustion of the patient. But there is another cause. In pro- 
tracted diseases, especially those of a diarrhoeal character, there is more or 
less wasting of the brain as well as of other parts. This naturally, by way 
of compensation, gives rise to congestion of the cerebral and meningeal veins 
and capillaries and to transudation of serum. 

The transudation commonly occurs in this malady over the superior sur- 
face of the brain and in the subarachnoidal space, perhaps also more or less 
in the lateral ventricles. So common is it in the last stage of infantile 
entero-colitis, the summer epidemic of cities, that this stage, which is really 
spurious hydrocephalus, has been called the stage of effusion. I shall relate 
in another place examples which show the anatomical character of this intes- 
tinal disease. . 

Symptoms. — Spurious hydrocephalus most frequently results from pro- 
tracted diarrhceal complaints. It may, however, result from any disease 
which is attended by great prostration. As it ordinarily occurs, the patient 
has for days or weeks been gradually losing flesh and strength. Finally, 
drowsiness supervenes, or before the drowsiness there is sometimes a period 
of irritability. 

Marshall Hall describes two stages of spurious hydrocephalus. In the 
first, he says, " the infant becomes irritable, restless, and feverish ; the face 
flushed, the surface hot, and the pulse frequent ; there is an undue sensitive- 
ness of the nerves of feeling, and the little patient starts on being touched 
or from any sudden noise ; there are sighing and moaning during sleep, and 
screaming ; the bowels are flatulent and loose and the evacuations are 
mucous and disordered." The second stage he describes as that of torpor. 
The first stage often, however, does not present those prominent symptoms 
which have been described by Dr. Hall, and this stage may even be absent 
or not appreciable, especially in young infants. 

Whether or not commencing with the stage of irritability, the disease, if 
not checked, gradually increases. The child soon becomes drowsy. He 
may be aroused for a moment, but unless constantly disturbed immediately 
relapses into sleep. He is sometimes fretful when aroused, but in other 
instances is quite indifferent, observing without apparent interest objects 
employed for the purpose of amusing him. Often there are indications of 
cerebral pain or distress, as contractions of the eyebrows, etc., but many of 
those affected are too young to make known their sensations. Convulsions 
sometimes occur toward the close of life, but they are not so common in this 
disease as in meningitis. When they do occur they are generally partial 
and often slight. The pulse is accelerated in most patients prior to and in 
the commencement of spurious hydrocephalus. As the disease advances it 
becomes irregular and intermittent, and toward the close of life it is pro- 
gressively more frequent and feeble. The respiration at first is not much 
disturbed, but at length it becomes irregular like the pulse. It is feeble and 
accompanied by sighs. Occasionally, there is slight cough. The eyelids 
are partly open, the pupils no longer respond to light, and in advanced cases 
they have a bleared appearance. The diarrhoea, which in most instances 
precedes and causes this malady, continues till the stage of stupor arrives, 



SPUMOUS HYDROCEPHALUS. 613 

when the evacuations becomes less frequent or cease altogether. In infants 
the stools are frequently green, in older children brown and sometimes 
slimy. The febrile heat of surfaces which preceded the disease, and which 
was present in its commencement, disappears ; the face and hands become 
cool, the features pallid, and the anterior fontanelle, if opened, is depressed. 
Death finally occurs in a state of coma, or if the disease be recognized and 
proper remedial measures employed, the result may be favorable, even when 
the symptoms are such that if meningeal inflammation were the malady we 
would consider the case necessarily fatal. 

In the following case the result was unfavorable. This case is interesting 
on account of the anatomical characters of the disease as disclosed by the 
post-mortem examination : 

Case. — " A German infant, eighteen months old, had diarrhoea four weeks with- 
out regular and proper medical attendance ; stools from the first brown and thin : 
during the last eight or nine days he has been drowsy ; when aroused opens his 
eyes and is very fretful, but immediately the upper eyelids gradually droop, and 
unless disturbed he remains asleep with his eyes partially open ; forehead warm, 
face cool and pallid, and limbs also rather cool : pulse 164, respiration 32 ; has had 
a slight cough about one week, and slight dulness on percussion over the left infra- 
scapular region: depression of inframammary region on inspiration. Treatment: 
Amnion, carbonat.. gr. 1 every two hours ; nourishing diet. 

" Dec. 20th, has continued drowsy since the last record ; pupils moderately 
dilated : a thick secretion between eyelids ; right pupil considerably larger than 
the left : vision apparently lost during the last three days ; pulse over 140 ; respira- 
tion 44 per minute, accompanied by sighing since the 18th; moans much when 
awake : rolls the head frequently ; during the last six days the surface back of the 
ears has been constantly sore by vesication ; takes the most nutritious diet with 
brandy. The stools remain thin and brown and number three or four daily. 

" From this date the diarrhoea continued, except as it was restrained by medi- 
cine. The pulse continued frequent and a slight cough remained. There was on 
the 21st and 22d partial abatement of the drowsiness, but on the 23d it was greater 
than ever. The body was somewhat reduced at the commencement of the cerebral 
symptoms, but it was now markedly emaciated. The prostration increased daily, 
and the hands were observed to tremble. The face and hands became more cool, 
while the head was warm. On the 24th partial convulsions occurred, followed by 
coma and death. 

•• The cerebral veins and sinuses were generally congested, except in the 
anterior portion of the brain, where the appearance was normal. Between the 
brain and its membranous covering, chiefly at the vertex and the base, was an 
effusion of clear serum. The whole amount of this fluid was estimated at two 
ounces. On slicing the brain numerous ' puncta vasculosa' were seen, both in 
the gray and white portions. With the exception of the congestion the sub- 
stance of the brain presented its normal appearance. No inflammatory lesions 
were present. We were not permitted to examine the condition of the intestines." 

Diagnosis. — The only disease with which spurious hydrocephalus is 
liable to be confounded is meningitis. The points of differential diagnosis 
are the history of the case, especially the antecedent diarrhoea or other ex- 
hausting ailment, evidence of prostration when the cerebral malady com- 
menced, depression of the anterior fontanelle if it be open, and the cool face 
and extremities. 

Prognosis.— If the pathological state of the brain be simple exhaustion, 
the disease can often be arrested by judicious treatment. If an incorrect 
diagnosis be made and the treatment employed be that appropriate for menin- 
gitis, which it simulates, death is almost inevitable. If transudation of 
serum have occurred, unless slight, the result is usually unfavorable what- 
ever may be the treatment. This disease in childhood is more easily man- 
aged than in infancy, but is less frequent. The prognosis is better in the 
cool months than during the heat of summer. It is more favorable if the 



614 LOCAL DISEASES. 

child be over than if under the age of one year. The occurrence of an 
irregular and intermittent pulse, of respiration accompanied by sighs, of 
inequality in the pupils or their sluggish movements, with increasing stupor, 
indicates an unfavorable issue. The cure of the primary disease, with the 
pulse and respiration still natural or accelerated, without change of rhythm, 
pupils sensitive to light, drowsiness from which the patient is easily aroused 
to a state of entire consciousness, render recovery probable with proper 
medication and alimentation. 

Treatment.— The indications of treatment are twofold : first, to remove 
the primary pathological state which is the cause of the spurious hydro- 
cephalus ; and, secondly, to cure the latter. The first is important, since 
the successful treatment of a disease requires the removal of the cause. 
The measures employed for this purpose are pointed out in our description 
of the diarrhoeal and other maladies which produce spurious hydrocephalus. 

We may here say that, as spurious hydrocephalus is due in a very large 
proportion of cases to the exhausting effect of long-continued diarrhoea, 
regulation of diet, subnitrate of bismuth, pepsin, and stimulation are needed. 

Active sustaining measures are indicated. Exhausted nervous power, as 
well as passive cerebral congestion, requires these. The diet should be 
highly nutritious, comprising such substances as milk and beef juice, and 
should be given frequently. Brandy is required at short intervals. Dr. 
Gooch was in the habit of giving the aromatic spirits of ammonia, properly 
diluted, as a quick and active stimulant. Six or eight drops may be given 
in sweetened water to a child one year old, and repeated every hour in cases 
of urgency. If by proper treatment of the cause and by the use of stimu- 
lants and nutritious food the patients do not within a few hours become less 
stupid and more conscious, there is that degree of prostration or of serous 
transudation from the engorged cerebral veins which will render death 
probable. In some cases it is proper to produce moderate vesication behind 
the ears. 



CHAPTER VII. 

ECLAMPSIA. 

The term " eclampsia " is used in a more restricted sense by some writers 
than by others. It is employed in the following pages to designate those 
convulsive seizures, clonic in their character, sometimes general, sometimes 
partial, which affect the external muscles, and are due to some exciting 
cause. It consists in rapid, forcible, and involuntary muscular contraction 
alternating with relaxation. It is distinguished from chorea in the fact that 
the latter is a more permanent state, and is characterized by muscular move- 
ments which are partially under the control of the will and are not so violent. 
The symptoms of eclampsia closely resemble those of epilepsy, but these 
diseases are distinguished from each other by characters which will be 
mentioned hereafter. 

Eclampsia occurs in a great variety of diseases, some of which are located 
in the cerebro-spinal system, some in other parts of the body, and some are 
constitutional. It may also be produced by temporary derangements of sys- 
tem not sufficiently severe to be considered diseases, and by powerful mental 
impressions, those of an emotional nature affecting the delicate and sensitive 
nervous system of the child. Pathologists recognize three different forms of 



ECLAMPSIA. 615 

eclampsia. The term essential or idiopathic is used when the convulsions 
have no appreciable anatomical character ; that is, when there is no apparent 
pathological state in the brain or elsewhere which gives rise to the attack. 
For example, if a child die in convulsions from fright, and all the organs, 
including the brain, are found in their normal state, the eclampsia is called 
idiopathic or essential. If the cause be disease of the brain or spinal cord, it 
is termed symptomatic. If eclampsia arise from local disease elsewhere than 
in the cerebro-spinal axis, as from pneumonia, the term sympathetic is em- 
ployed. This is in the main a good division, but eclampsia may be at the 
same time sympathetic and symptomatic, as when it occurs in consequence 
of congestion of brain which is induced by severe and frequent paroxysms 
of whooping cough. 

Causes. — Eclampsia occurs at any period of infancy and childhood, but 
it is much more rare after the period of six or seven years than previously. 
Some children are more liable to it than others. It is produced in one by 
an agency which in another has no appreciable effect. There are some, gen- 
erally those of an impressible nervous system, who are seized with convul- 
sions whenever there is any slight derangement in the digestive or other 
organs. Eclampsia is frequent in certain families. Thus, Bouchut mentions 
a family of ten persons all of whom had convulsions in their infancy. One 
of them married and had ten children, who, with one exception, had convul- 
sions. 

The exciting causes of eclampsia are too numerous to be mentioned in 
full. It is a symptom in nearly all cerebral diseases. It is produced in the 
nursling by changes in the milk with which it is nourished. These changes 
are usually due to violent emotions of the mother, as anger, fright, and 
grief, to the use of acescent or indigestible food, or to derangement, tempo- 
rary or permanent, in their health. Thus, in a case related to me the cata- 
menia so affected the milk that? the infant was seized with eclampsia at each 
monthly period. In childhood the most common cause of clonic convulsions 
is the presence of some irritant in the primae viae. All kinds of fruit, even 
the mildest, may produce eclampsia, especially when eaten unripe or taken 
in undue quantity. I have known an infant to be seized with convulsions 
from eating strawberries, which parents usually regard as harmless, and one 
of the most violent and protracted cases of eclampsia which I have wit- 
nessed occurred in a child over the age of six years from swallowing, in con- 
siderable quantity, the parenchymatous portion of an orange. Constipation, 
worms, dysentery, intussusception, and painful dentition are also causes 
which are located in the digestive apparatus. Inflammation in some part of 
the respiratory apparatus is a not infrequent cause. Thus, eclampsia occurs 
occasionally in severe coryza, in consequence, according to some, of the 
proximity of the inflamed surface to the brain and the consequent afflux of 
blood to this organ. It is a common complication also of pertussis and 
pneumonia. It occurs often at the commencement of two of the eruptive 
fevers — namely, smallpox and scarlet fever, and in the course of the latter 
disease. 

Violent emotions of the child may also cause eclampsia. Bouchut relates 
the case of a girl five years old who was corrected before her companions, 
and was so affected by anger that convulsions ensued. Residence in close 
and overheated apartments or in streets where the air is loaded with offen- 
sive vapors and is stifling, is a predisposing cause, so that there is a larger 
proportion of deaths from convulsions in the cities than in the country. 

In young children burns, even when not very severe, are liable to termi- 
nate suddenly in eclampsia, succeeded by coma and death. Urinary calculi, 
both renal and vesical, may produce the same result. 



616 LOCAL DISEASES. 

Such are the more common causes of eclampsia. It is seen that they 
are of two kinds, predisposing and exciting. An excitable or impressible 
state of the nervous system constitutes the chief predisposition to the dis- 
ease. Plethora, or its opposite state ansemia, increases the liability to an 
attack. 

Premonitory Stage. — In the majority of cases there are prodromic 
symptoms which the experienced and careful physician can detect so as to 
forewarn friends. The child is perhaps more or less drowsy, and, when dis- 
turbed, fretful. The eyes often have a wild or unnatural appearance ;' occa- 
sionally they are fixed for a moment on an object, and yet apparently with- 
out noticing it. The sleep is disturbed ; in some there is unusual heat of 
head, and, if old enough, complaint of headache. At times, especially if the 
primary disease be febrile or - inflammatory, there is incoherence of thought 
or expression, or even actual delirium. In some children when eclampsia is 
threatening the thumbs are seen to be carried across the palms. I have 
observed this especially during the convulsive cough of pertussis. A very 
important prognostic symptom is sudden starting or twitching of the limbs. 
This shows that the nervous system is profoundly impressed, and but slight 
additional excitation is required to develop eclampsia. This sudden starting 
not infrequently precedes the attack several hours and gives suflicient fore- 
warning. 

The prodromic symptoms are often disregarded by friends who do not 
understand their significance. Even physicians, in the haste of their visits, 
in many instances do not notice them. The S} T mptoms which precede symp- 
tomatic and sympathetic eclampsia are, moreover, blended with those of the 
primary affection, and hence another reason why they are frequently over- 
looked. When the convulsions are about to commence the child generally 
lies quiet ; the eyes are open and fixed. If spoken to or shaken he takes no 
notice and does not speak. The direction of the eyes is then changed ; often 
they are turned up ; occasionally there is strabismus. The face may be pale 
or flushed, and sometimes, especially in cerebral diseases, the features present 
patches or streaks of a flushed appearance, while around them the natural 
color is preserved. Immediately before the spasmodic movements, the child 
sometimes utters a piercing scream, which is probably involuntary, though it 
seems like a supplication for help. The duration of the prodromic stage is 
very different in different cases. It may last from a few minutes to several 
hours, or even more than a day. 

Symptoms. — Eclampsia is general or partial. If general, the muscles of 
the face, eyes, eyelids, and of all the limbs are in a state of rapid involuntary 
contraction, alternating with relaxation. The features lose their natural 
expression and are distorted ; the mouth is drawn out of shape, often to one 
side, by the violent muscular action ; the teeth are pressed together by tonic 
contraction of the masseters, and may be violently struck together, so as to 
lacerate the tongue if it protrude, or are ground upon each other. Unless 
the attack be of short duration, frothy saliva, perhaps tinged with blood from 
the injured tongue, collects between the lips. The eyelids are usually open, 
and in severe cases the eyes are turned so that the pupils are lost under the 
upper eyelids, or the muscles of the eyes are involved in the spasmodic move- 
ment so that the eyeballs are forcibly drawn from side to side. Occasionally 
strabismus occurs. While the features are thus distorted the head is strongly 
retracted or is turned to one side ; the forearms are alternately pronated and 
supinated ; the thumbs and fingers are convulsively flexed, so that the thumbs 
lie across the palms and are covered by the fingers ; the great toe is adducted, 
the other toes flexed ; and the toes, as well as legs, participate more or less in 
the spasmodic movements. 



ECLAMPSIA. 617 

In general convulsions, consciousness is usually lost. The head is hot 
previously to and during the attack — at least in the first part of it — and the 
face flushed. In exceptional cases, especially in sympathetic eclampsia, the 
head is cool and the face pallid. The pulse is somewhat accelerated, as well 
as the respiration, and the latter is rendered irregular if the respiratory mus- 
cles, especially those of the larynx, are involved, as they generally are. The 
sphincters are relaxed during the convulsive attack, so that in many cases the 
urine and stools are passed involuntarily. 

Partial eclampsia is more common than the general form ; it occurs in 
the muscles of the face, including those of the eye, of the face and of one 
or both upper extremities, or of the face and the extremities on one side. 
The spasmodic movements may be even limited to the muscles of the eye, 
and they often occur only in these muscles and those of the face. Rarely, 
if ever, does eclampsia affect the legs without affecting also the muscles of 
the arms and face. In partial convulsive attacks sensation and consciousness 
are in some patients not entirely lost, but in others they are not manifested 
if present. 

The duration of an attack of eclampsia varies in different cases from a 
few minutes to several hours, with an average of not more than from five to 
fifteen minutes. The movements do not often continue longer than three or 
four hours in the severest cases. They are sometimes said to last a much 
longer time, even for days, but in these cases there are intermissions. Violent 
attacks are usually short. 

When the convulsion ends favorably the spasmodic movements become 
less and less strong, and finally cease. The child then takes a deep inspira- 
tion, after which it lies quiet, and the respiration remains regular or mode- 
rately accelerated. Some fully recover in a few minutes if the eclampsia 
have been light and the cause transient, and seem to experience no incon- 
venience except soreness of the muscles and fatigue. Others soon recover 
consciousness, and their temperature, respiration, and circulation become 
natural, but they remain dull for a time, their minds are bewildered, and 
they are perhaps unable to speak. In a few hours these untoward symptoms 
pass away. In essential, and in a large proportion of cases of sympathetic, 
eclampsia, if properly treated and if the cause be recognized and removed, 
there is no recurrence of the convulsion ; in others it is different. In many 
cases, especially of symptomatic eclampsia, and of sympathetic in which the 
cause is grave and persistent, the convulsions return after a variable period 
of a few minutes or a few hours. Six or eight or more convulsions may 
occur within twenty-four hours. Rarely they occur several times daily for 
several consecutive days, but severe convulsions, repeated at short intervals 
for twenty-four or forty-eight hours, usually end in fatal congestion of the 
brain or serous effusion. I once attended an infant about six months old 
who had from four to twelve convulsions daily for eleven days, caused prob- 
ably by a vesical calculus, as there was dysuria and at times bloody urine. 
Some days after the convulsions were controlled, while we were deferring 
exploration of the bladder, death occurred suddenly, and an autopsy was not 
permitted. This case will be detailed elsewhere. Bouchut has witnessed a 
case of whooping cough in which there were daily convulsions for eighteen 
days. 

In severe eclampsia the respiration is so embarrassed and circulation so 
retarded that congestion of various organs results. This passive congestion 
in the respiratory organs is indicated by moist rales in the larynx and bron- 
chial tubes ; occurring in the brain, it is indicated by profound stupor. It 
has already been stated that death may occur from the cerebral congestion, 
which, continuing, is apt to end in effusion of serum or extravasation of blood. 



618 LOCAL DISEASES. 

In these cases the convulsive movements cease, but there is no return of con- 
sciousness. The child lies quiet, as if in sleep, with pupils not readily acted 
on by light, and often somewhat dilated ; gradually the limbs grow cool and 
the pulse feeble, and fatal coma supervenes. 

Death does not ordinarily occur from one attack. There are several at 
intervals, during which the stupor is gradually becoming more and more pro- 
found, till finally total loss of consciousness and sensation results, terminating 
in death. Apnoaa may occur in the first attack, ending life abruptly and 
unexpectedly, but in other instances it does not result till after several seiz- 
ures, when at length one more violent than the others interrupts the respira- 
tory function and causes death. 

Occasionally when life is preserved there is some permanent ill-effect of 
eclampsia. Bouchut says : " The origin of certain permanent contractions 
which bring on deviation of the head or other parts, retraction of the limb, 
paralysis, etc., must be referred to the convulsions of the muscles. I have 
seen several children in whom torticollis had no other cause. The drooping 
of the upper eyelid, strabismus, irregularity of the mouth, severe contractions 
of the limbs, often depend on this influence. These accidents are consequences 
of essential as well as of symptomatic convulsions." 

Anatomical Characters. — The morbid anatomy pertaining to eclamp- 
sia is in most cases twofold : first, the pathological states which precede and 
cause the convulsive movements ; secondly, those which result from them. 
We have seen that in sympathetic eclampsia the diseases which sustain a 
causal relation are very numerous ; some are constitutional, others local, and 
the latter may have their seat in almost any part of the economy distinct 
from the cerebro-spinal axis. In some cases of sympathetic eclampsia the 
immediate cause is a too active circulation, a state of hyperemia of the cere- 
bral vessels. 

It has already been stated that this hyperemia may be diagnosticated in 
young infants in whom the anterior fontanelle is open. Such infants, seized 
with acute inflammation of one of the mucous surfaces, often present a full 
and rapid pulse and a convex and forcibly pulsating fontanelle before the 
eclampsia begins. In other cases of sympathetic eclampsia the primary 
disease induces passive congestion of the brain, and this in turn gives rise to 
convulsions. Eclampsia occurring during the paroxysms of whooping cough 
affords an example. 

In some cases of sympathetic eclampsia the convulsive movements are pro- 
duced by the primary disease acting directly on the nervous system through 
the medium of the nerves, without causing any appreciable alteration in the 
state of the cerebro-spinal axis. Thus, Barrier relates three fatal cases of 
convulsions occurring in pneumonia, in none of which was there anything 
abnormal in the condition of the brain or its membranes. 

The pathological state preceding symptomatic eclampsia differs in differ- 
ent cases, since convulsions occur in almost every disease of the brain and 
its membranes. The immediate cause of this form of eclampsia may be 
active or passive cerebral congestion, with or without effusion ; it may be 
compression of the brain from various causes ; it may be a deficiency as well 
as excess of the cerebro-spinal fluid. 

The congestion resulting from eclampsia may give rise to extravasation 
of blood and the formation of a clot. If this accident occur, there is often 
paralysis affecting more or less of one side permanently, or gradually disap- 
pearing. 

It may be difficult to decide whether the cerebral congestion precedes the 
eclampsia or is its result ; but in those cases in which it precedes and operates 
as a cause it is no doubt increased during the convulsive period. The spas- 



ECLAMPSIA. 619 

modie muscular action, by rendering respiration irregular and imperfect, also 
leads to congestion of the lungs, and sometimes of other organs. 

Diagnosis. — The only disease which resembles eclampsia is epilepsy, but 
the diagnosis can ordinarily be made by recollecting the following facts : — 
Eclampsia is most common in infancy. If it occur after the age of three 
years there is some manifest exciting cause which renders the child seriously 
sick independently of the convulsions, and prior also to their occurrence. But 
in epilepsy first attacks are very often mild — the petit mat of writers ; in other 
cases they are tolerably severe from the first; but, whether mild or severe, 
they occur with no previous or coexisting sickness and with little or no warning. 

The symptoms in eclampsia and epilepsy are identical, except as the 
causes of eclampsia produce certain concomitant symptoms, and there is 
every reason to believe that the spasmodic muscular movements proceed 
from an irritation of the same portion of the cerebro-spinal axis — to wit, the 
medulla oblongata. Writers like Niemeyer have given reasons for the belief 
that spasmodic muscular movements are produced by functional disturbance 
of this part of the nervous centre. I may state the following, to which I am 
not aware that any one has alluded : If the exposed medulla of an acephalous 
monster be pressed or pinched, convulsions like those of eclampsia and epilepsy 
result. These two diseases, therefore, have a close resemblance anatomically 
and clinically, but by attention to the above facts they can ordinarily be 
distinguished from each other. 

In most cases of eclampsia the child has fever or other pronounced symp- 
toms of the primary disease, which suffice for diagnosis ; but we have fre- 
quently examined epileptics in the Bureau for the Relief of the Out-door 
Poor whose first attacks were evidently produced by some exciting cause, and 
were eclamptic. One attack of clonic convulsions predisposes to another, and 
therefore eclampsia, if the attack be repeated a few times, not infrequently 
ends in epilepsy. The convulsions, which at first are produced by an obvious 
cause, now occur without apparent cause. 

It is often difficult to ascertain the form of eclampsia, whether essential, 
symptomatic, or sympathetic — in other words, to determine the cause — till 
after the convulsions cease. This is especially true when, as is frequently 
the case, the physician is not summoned till the convulsive movements begin. 
and it is necessary that he should act promptly, with but little knowledge 
of the child's previous history. If there be an obvious antecedent disease, 
as whooping cough or meningitis, the cause is apparent ; but if the previous 
health have been good or but slightly disturbed, it may be necessary to make 
more than one visit or examination in order to ascertain the seat and character 
of the cause. In the majority of cases of convulsions occurring suddenly in a 
state of previous good health the cause is seated in the intestines, but sudden 
and unexpected attacks may be due to the commencement of some inflamma- 
tory affection, as pneumonia, or of a febrile disease, as smallpox. Unless the 
eclampsia be speedily fatal, the physician, if he examine carefully, will in 
most cases soon be able to ascertain the nature of the cause and diagnosticate 
the form of the disease. 

Prognosis. — Symptomatic eclampsia is always serious. If it occur in 
the course of a cerebral disease, it indicates the approach of death, but if at 
its commencement, the patient may recover. Its recurrence, whatever the 
cerebral disease, is usually prognostic of death. 

In idiopathic or essential convulsions the prognosis depends on the severity 
of the attack and on the age, strength, and previous condition oi % the child 
If there be predisposing or co-operating causes, as a nervous or excitable 
temperament or dentition, the prognosis is less favorable than when such 
causes are absent. 



620 LOCAL DISEASES. 

In sympathetic eclampsia the prognosis varies greatly, according to the 
nature of the primary disease and often according to the stage of that disease. 
If convulsions occur at the commencement of an eruptive fever, they generally 
subside without untoward symptoms and the fever pursues a favorable course. 
Eclampsia after the appearance of the eruption is premonitory of a fatal result. 
I have not yet known a patient with scarlet fever recover who had convul- 
sions after the rash had covered the body, and experienced physicians of this 
city tell me that their observations correspond with mine. Dr. J. F. Meigs, 
however, relates one favorable case. If the cause of the eclampsia be located 
in or upon the mucous surfaces, a majority recover with judicious treatment. 
In convulsions consequent upon pneumonia or a burn, more die than recover. 

The prognosis in eclampsia is more favorable if the parallelism of the eyes 
be retained, the pupils remain sensitive to light, and consciousness soon return. 
A fatal termination may be predicted if, after the convulsion, the child remain 
stupid, without any evidence of returning consciousness, and the pupils do not 
respond to light. 

Treatment. — Fortunately, inasmuch as the physician is often required 
to treat eclampsia in ignorance of the cause, the same measures are demanded 
to a considerable extent in all cases, whether the form be essential, sympto- 
matic, or sympathetic. As early as possible in the attack the feet should be 
placed in hot water to which mustard is added, or if it can be procured with 
little delay a general warm bath may be used in its place. This has a sooth- 
ing effect upon the nervous system and promotes muscular relaxation, while 
it also produces derivation of blood from the cerebro-spinal axis. It is there- 
fore useful, especially in those cases in which active or passive congestion 
precedes the eclampsia ; it is also useful as a preventive of passive conges- 
tion and consequent cedema of the brain, lungs, and other organs, which are 
the most serious results of eclampsia. It should be continued from six to 
fifteen or twenty minutes, according to the severity and duration of the 
attack ; at the same time cold applications should be made to the head until 
its temperature, which is usually increased, is reduced. The application of 
cloths placed upon ice or frequently wrung out of cold water is the most 
convenient and ready mode of employing this agent. Cold thus employed 
acts promptly in contracting the vessels of the brain and meninges and 
diminishing the cerebral congestion. It tends, therefore, to remove one of 
the chief dangers. 

Cold applications are also useful for reducing an elevated temperature if 
it be present. In most cases of eclampsia, if the temperature reach 103°, the 
necessity for its reduction is urgent, and the cold cloths or India-rubber bag 
containing ice should be applied not only upon the head, but also along the 
sides of the face, and sometimes over the great vessels of the neck. 

Since a large proportion of convulsive attacks originate in the condition 
of the intestines, either solely or in part, it is advisable to prescribe an 
aperient unless there be previous diarrhoea. 

The common enema of soap and water will usually produce a free and 
speedy evacuation, and will sometimes disclose the cause of the eclampsia in 
the expulsion of seeds or other indigestible substances or scybala. A cathartic 
is also often required, especially if the enema fail to produce sufficient evacu- 
ations. In those that are robust, and especially in those beyond the age of 
two or three years, calomel is an excellent purgative, is easily given, and is 
prompt in its action. If the symptoms indicate intestinal inflammation, the 
milder purgatives, as castor oil, are preferable, as they also are in young or 
feeble children. If the recent ingesta of the patient consisted of fruit or of 
substances of an indigestible character, an emetic is appropriate ; a teaspoon- 
ful of the syrup of ipecacuanha, repeated if necessary in fifteen or twenty 



ECLAMPSIA. 621 

minutes, may be given to a young child, or this syrup mixed with the syrup 
scillie compositus to one older and more robust. Aside from the ejection of 
the offending substance which it produces, an emetic has some effect in con- 
trolling the convulsive movements. But the cases are rare in which emetics 
are indicated. 

In addition to the local measures mentioned above, and measures calcu- 
lated to relieve the digestive canal of any offending substance, a safe medici- 
nal agent which will act promptly in relieving the convulsions is urgently 
demanded, since eclampsia, if severe and protracted, involves great danger. 
Fortunately, such agents have been lately introduced into therapeutics — 
namely, the bromide of potassium or sodium and hydrate of chloral. These 
agents, while they are effectual, are safe, and therefore their use has sup- 
planted that of the antispasmodics — asafcetida, valerian, lavender, and chloro- 
form — formerly employed ; not one of which, except chloroform, exerts any 
direct controlling influence over the convulsions, and chloroform is a danger- 
ous remedy unless used sparingly. 

The bromide of potassium, which I prefer, should be given every ten 
minutes, dissolved in cold water, till the convulsions cease, in doses of four 
grains to a child of one year, and of five to eight grains to a child of two or 
three years. When the convulsions cease the interval between the doses 
should be lengthened. In one instance in my practice an infant of eighteen 
months was suddenly seized with eclampsia, and the mother, in her fright 
mistaking the directions, gave thirty grains of bromide at one dose. Two 
hours afterward, when I was able to attend, I found that the convulsions had 
ceased at once and that the patient was playful. Such cases show the innoc- 
uousness of a large dose of the bromide and the safety in administering the 
medicinal dose often. 

In severe cases the bromide does not always act with sufficient prompt- 
ness and power. The hydrate of chloral should then be employed, given by 
the mouth or dissolved in two or three drachms of water and given with 
a small glass or gutta-percha syringe per rectum. If used in sufficient 
quantity, per rectum, and retained by pressure with a napkin, it is quickly 
absorbed, and will usually in about fifteen or twenty minutes control the 
eclampsia. For a child of one year I employ about two grains, and for one 
of four years four grains, given by the mouth, or double this quantity given 
per rectum. With the use of the measures indicated above eclampsia is, in 
my practice, much more amenable to treatment than in former years. Unless 
the cause be such that recovery is impossible from the very nature of the 
case, the convulsions will soon cease with these measures. It is interesting 
to observe the effect of the chloral enema. In from five to ten minutes 
the convulsive movements cease in the muscles of the face, a moment later 
in those of the arms, and lastly in those of the lower extremities. 

But additional treatment may be required, according to the pathological 
state which has brought on the eclampsia. If it be an eruptive fever, as 
scarlatina, and the eruption have receded, active revulsive measures, as hot 
mustard baths, are required; if in dysentery or other internal inflammation, 
the flaxseed and mustard poultice should be applied over the parts affected. 

In those dangerous cases in which symptoms of cerebral congestion con- 
tinue after the eclampsia ceases additional treatment is required. The child 
remains drowsy, does not speak or apparently suffer in any way. and the 
pupils act less readily than in health. If this condition remain after the 
lapse of a few hours there is probably serous effusion. All attacks of 
eclampsia, unless the mildest, are followed by a period of drowsiness, but 
the persistence of it, with symptoms which indicate hyperemia, with per- 
haps effusion within the cranium, calls for the employment of additional 



622 LOCAL DISEASES. 

measures. Vesication by cantharidal collodion should then be produced 
behind the ears, mild revulsives be applied to the extremities, the head kept 
cool, the bowels open, and in certain cases a diuretic like iodide of potassium 
may be advantageously employed. The utmost care should be enjoined in 
reference to the hygienic management of those who are subject to eclampsia. 
The diet should be nutritious but bland, and all causes of excitement be 
studiously avoided. 



CHAPTER VIII. 

EPILEPSY. 

Epilepsy is a paroxysmal disease. The paroxysms are manifested by 
impairment or loss of consciousness, and in fully-developed and typical cases 
also by convulsive movements of more or fewer of the voluntary muscles. 
Epilepsy is a neurosis or functional affection of the nervous system, not due, 
therefore, to any appreciable structural change in the brain or spine. The 
convulsions are tonic or clonic, or most frequently both, the tonic preceding 
the clonic. 

Etiology. — In a large proportion of cases we are able to discover both 
predisposing and exciting causes of the first attack, but one convulsion pro- 
duces such a change in the nervous system that the liability to another 
attack is increased. Hence after the epileptic habit is established after one 
or a few attacks, convulsions usually occur without any apparent exciting 
causes ; and if such a cause be discovered, it is evidently insufficient without 
the presence of a strong predisposition. 

Predisposing Causes. — Prominent among these is a neurotic inherit- 
ance. Echiverria, whose observations were made in the epileptic wards on 
Blackwelfs Island, states that 28 per cent, of the 300 epileptic patients 
examined by himself presented evidences of inheritance. In Reynolds's 
cases the number was 31 per cent., and in 1218 cases examined by Gowers 
the number who presented evidences of an inherited predisposition was 429, 
or 35 per cent. The morbid state in the parent which gives rise to an inher- 
ited predisposition to epilepsy in the child is most frequently epilepsy or 
insanity. Less frequently, according to Gowers, the parental disease is 
chorea, hysteria, or a spinal malady. Inherited predisposition is said to be 
more frequently from the mother than from the father. The occurrence of 
epilepsy in a brother or sister renders it probable that the patient has inher- 
ited a predisposition, although we may be unable to trace it to either parent 
or any of the ancestry. The evidence of a strongly inherited predisposition is 
sometimes apparent by the number of near relatives affected by the same dis- 
ease. Thus, Gowers states that in one instance the patient's mother, aunt, 
two uncles, and a cousin were epileptic, and in another instance fourteen near 
relatives had epilepsy. 

Age. — Statistics relating to the age at which epilepsy begins have been 
published by Haase, Gowers, and others. These show that three-fourths of 
the cases begin under the age of twenty years, one-fourth under the age of 
ten years, and about one-eighth under the age of three years. 

Exciting Causes. — Immediate or exciting causes of epilepsy are usu- 
ally most apparent in cases which begin during infancy or childhood. The 
history of a large number of epileptic children has been ascertained during 



EPILEPSY. 623 

the last twenty years in the children's class in the Out-door Department at 
Bellevue. and very frequently we were informed that at the first attack the 
child was feverish or constipated or had some acute ailment, which served as 
the exciting cause. Often the first convulsions were attributed to dentition, 
but we now know that most of the cases which were attributed by the parents 
to teething are due to other causes, as constipation, diarrhoea, the presence of 
indigestible or irritating ingesta in the intestines, rachitis, or some acute 
infectious or inflammatory disease. If the child have a succession of dis- 
eases giving rise to convulsions, they may be sufficient to establish the epi- 
leptic habit, even when there is no apparent predisposition to epilepsy. 
Thus. Gowers relates the case of a child of healthy parentage and without 
any inherited predisposition, that had a fit at the age of six months, attrib- 
uted to teething ; another at the age of two years, from scarlet fever ; 
another at four and a half years, from measles ; and another at sixteen and 
a half years, from a carbuncle. These repeated convulsive attacks ended in 
a permanent epilepsy. 

Mental Emotion. — Fright or great excitement, from whatever cause, is 
the most common and potent of the immediate causes of epilepsy. It pro- 
duced the first convulsive attack in 157 of Gowers's cases, or in more than 
one-third of those in which an exciting cause was assigned. This cause is 
operative chiefly in the periods of childhood and youth, when the emotions 
are strong, and in females more frequently than in males. Among the enu- 
merated causes of the mental excitement, authors mention fire-alarms, burg- 
laries, thunder-storms, and pretended ghosts. Gowers states that a soldier 
on sentry-duty at night was so frightened by some white goats that appeared 
suddenly on the wall of an adjacent cemetery that he was seized with con- 
vulsions and became an epileptic. Sudden and profound emotion has some- 
times been the exciting cause of chorea, and in some instances of epilepsy, 
cases which I have observed ; in one instance in an emotional child, the sight 
of the corpse of a favorite uncle producing this result. In another instance 
a physician of my acquaintance, in treating a female child with scarlatinous 
nephritis, ordered a warm bath. The next day, visiting the patient and 
learning that his directions had not been heeded, he prepared a bath and in a 
rude manner plunged the child into it. She was much frightened, and imme- 
diately had a severe convulsion. The scarlatinous uraemia probably predis- 
posed to the attack, but the fright was the exciting cause. She has been a 
confirmed epileptic from that day, the fits being frequent and severe. Treat- 
ment employed at intervals during the last ten or twelve years has had but 
little effect in controlling them. Gowers states that in an aggregate of 76 
cases in which epilepsy resulted from fright, the convulsion occurred imme- 
diately in 28, within a few hours in 16 others, after the first day, but within 
seven days, in 19, and at a later period than one week in 13. 

Protracted cares or anxieties, which prevented the needed mental rest, 
have also in some instances been the only assignable cause of epilepsy, but 
this cause is less frequent in childhood than in adult life. 

Traumatism. — Usually the injury received is upon the head, either from 
a fall or a blow, by which the patient is stunned or rendered unconscious for 
a time. The convulsion may occur immediately or not until the lapse of a 
day or more. Traumatism is ordinarily attended by much mental excite- 
ment, and this has its influence in producing the convulsive attack. 

Among the less frequent but occasional causes of epilepsy in infancy and 
childhood we may mention inherited syphilis, intestinal worms, scarlet fever, 
measles, pneumonia, rheumatism, exposure to a high degree of heat, especi- 
ally to the sun's rays, masturbation, renal disease, and peripheral causes 
having a reflex action, as phimosis, cicatrices, and a decayed tooth. When 



624 LOCAL DISEASES. 

these causes are removed, the clonic convulsions which they have produced 
may cease, but in other instances they continue, the epileptic habit having 
been established. 

Symptoms. — Two forms of epilepsy have long been recognized and 
described in standard treatises — the mild and severe forms, the epilepsia 
mitior and epilepsia gravior ; or, in the French language, le petit mal and le 
grand mal. As the terms imply, this classification is based on the difference 
in the severity of the attacks. 

Minor Attacks. — These are characterized by momentary dizziness and 
usually loss of consciousness. The patient has a bewildered look ; his speech 
is interrupted, even in the middle of a sentence, and his work, whatever it 
may be, is also interrupted, so that whatever he is holding drops from his 
hands. His pallor, bewildered look, and strange actions attract attention, 
but in a moment he resumes his work and his speech. When the attack is 
over he may be at once in his ordinary mental and physical condition, and 
seem quite well, but he does not have a clear recollection of what, has hap- 
pened. Some patients after the attack ceases remain for a time in a drowsy 
state and without full perception, or their speech and acts may be passionate 
and violent until they regain their normal state. 

Major Attacks. — These begin abruptly with strong tonic contraction of 
the muscles, which causes rotation of the head to one side, a fixed lateral, 
and sometimes upward, deviation of the eyes, and a constrained and awk- 
ward position of the extremities. The facial, thoracic, and abdominal mus- 
cles participate, causing distorted features and embarrassment of respiration. 
The face, at first pallid, soon becomes livid, the pupils are dilated, the con- 
junctiva insensitive, and the eyes are in some patients open, but in others 
closed. The cyanosis deepens and the surface becomes very livid. In a 
moment the muscles begin to vibrate and undergo alternate relaxations and 
contractions. The second stage, or that of clonic convulsions, begins. The 
head, face, body, and limbs are violently jerked, saliva tinged with blood 
flows from the mouth, and sometimes the urine and feces are expelled. The 
patient presents a striking and shocking spectacle, which gave rise in olden 
times to the belief of demoniacal possession. Presently the muscular relaxa- 
tions become longer, more air is inhaled, and the blueness, which was in- 
tense, begins to abate. The muscular contractions, though as severe as at 
first, are less frequent, and finally cease, and the patient, weak and uncon- 
scious, sleeps quietly but soundly. Occasionally, instead of a simultaneous 
commencement of the attack in all parts of the body, it begins in one region 
and extends to others on the same side, and then, diminishing on this side, 
it begins on the opposite side. In this form of epilepsy the patient may not 
lose consciousness until late in the attack, so that he at first is aware of his 
condition, and the convulsions may be clonic from the first. 

Aura. — Certain patients exhibit symptoms which are premonitory of the 
attack some hours before its occurrence. One of these is the sudden jerking 
of certain muscles, as of the arms or legs. This usually occurs when the 
patient is awake, but it may occur when he is asleep or is falling asleep. 
Another occasional premonitory symptom is persistent dizziness, preceding 
the attack some hours or even days. A ravenous appetite, a stifling sensa- 
tion in the chest, as if from want of air, numbness, cephalalgia, impairment 
of sight, the vision of red fiery sparks (Aretaeus), and irritability of temper 
occasionally precede the attacks, so as to forewarn the patient and friends. 
Bootius in 16-49 described a premonitory symptom which was observed in rare 
instances, but which was thought to justify the recognition of a variety of 
the disease that was designated epilepsia cursiva. The patient ran a short dis- 
tance and then was seized with the convulsion. Another similar precursory 



EPILEPSY. 625 

symptom immediately preceding the attack is mentioned by some writers. 
The patient, if walking, even if entering his home, turns around, retraces 
his steps, and falls down in a fit. The premonitory symptoms described 
above, which enable the epileptic, with the aid of his friends, to reach a 
place of safety before the attack begins, occurs in a small proportion of cases. 

Many epileptic fits begin with an aura — a term first employed by Pelops, 
the predecessor and teacher of Galen, to indicate a sensation which com- 
mences in some part away from the brain and ascends toward it. In olden 
times the aura was supposed to be a vapor, which traversed the vessels to the 
brain and caused the attack. It is now known that it ordinarily has a cen- 
tral origin, is due to commencing functional disturbance of the brain, and is 
a part of the fit. It is true that the immediate application of a ligature or 
tight band above the aura, which arrests its ascension to the brain, will often 
prevent the fit, but Odier, Brown-Sequard, and Growers have shown that this 
occurs in epilepsy due to cerebral tumors, even more frequently than in epi- 
lepsy which has no appreciable anatomical cause. Therefore, this fact of the 
arrest of the convulsion by ligation above the aura cannot be employed as an 
argument in support of the theory of the peripheral origin of the attacks. 

The statistics of Romberg, Sieveking, and Gowers show that an aura 
occurs in about half the cases. The aura may begin in any peripheral por- 
tion of the system, in any of the organs of the special senses, and in many 
of the internal organs. By knowing from what portion of the brain the 
nerve arises which supplies the part that is the seat of the aura, we are 
enabled to state which of the divisions of the brain is probably so affected 
as to produce epilepsy. 

The aura varies greatly in its character as well as location. It is a sen- 
sation of pain, numbness, burning or tingling, or, instead of being sensory, it 
may be wholly or chiefly motor, as cramps, jerking, twitching of a certain 
muscle or group of muscles may occur. Sometimes the aura is at the same 
time both sensory and motor. The sensory aura commonly ascends, as we 
have already stated, toward the head, but it occasionally descends a limb, 
and when it reaches a certain point the convulsion begins. The aura often 
occurs in one side of the face, tongue, or trunk, or in one limb. In other 
instances it is bilateral or general, commencing simultaneously in correspond- 
ing limbs of the two sides. Auras in the trunk, and not in the viscera, occur 
almost entirely in the back, along the spine, and are known as the spinal 
aurae. General auras are sometimes characterized by faintness, malaise, or 
powerlessness, or a general tremor or a general sensation of coldness or of 
heat. Visceral aurae occur for the most part in viscera supplied by the 
pneumogastric. The most common of these auras is the epigastric, a pain 
or a sensation in the epigastrium, vaguely described as a " heat," " coldness," 
" trembling," a " twisting " or "winding up." The epigastric aura may be a 
little above or below or to the left of the epigastrium. In some cases the 
aura is located in the chest or throat. A sensation of suffocation or tingling 
or burning, or an indescribable feeling, is experienced in the chest or throat 
immediately before the attack begins. The patient perhaps presses upon his 
chest or throat with his hands and immediately becomes convulsed. The 
heart also derives its innervation from the pneumogastric, and the aura is 
sometimes referred to this organ. In some patients the cardiac region is the 
seat of a vague sensation variously described, or the aura may be manifested 
by increased action or palpitation, with perhaps more or less dyspnoea. Of 
the cephalic auras, vertigo is perhaps the most common, attended in some by 
rotation of the head and occasionally of the body. In certain epileptics 
there is the sensation of rotation without actual movement, and in some 
instances objects seem to move. Cephalic auras in a considerable number of 
40 



626 LOCAL DISEASES. 

instances consist of headache or a sensation in the head described as heavi- 
ness, pressure, coldness, burning, etc. 

In certain cases the aurae are entirely emotional, having usually the form 
of fear, which is sometimes so great that extreme terror is depicted on the 
countenance, and yet there may be no remembrance of it after the convulsion 
is over. In a considerable number of instances the aurae are manifested in the 
organs of the special senses, and consist in an aberration of their functions. 
The olfactory aura is usually an unpleasant smell, as of sulphur, putrid mat- 
ter, pus, decaying animal substances. The gustatory aura is a bitter, sour, 
metallic, or nauseous taste. The ocular aura is an unusual sensation in the 
eye — diplopia, an apparent change in the size of objects viewed, sudden 
blindness, or the perception of unusual or striking objects, as a flash, sparks, 
colored lights, or persons or things not present, sometimes quiet, sometimes 
in motion. The auditory sensations occurring as aurae are sounds of many 
kinds — of music, of bells, thunder, a whistle, the wind, an explosion or any 
other startling sound. It is seen that the aurae, although having a central 
origin, occur in almost every part of the system, remote from as well as near 
the brain, and are of many different kinds. 

In some epileptics a harsh scream or groan announces the commencement 
of the fit, but in children, according to my observations, it rarely occurs. It 
is apparently produced by a spasm of the laryngeal muscles, which causes 
narrowing of the passage through the larynx, and a spasmodic contraction 
of the thoracic and abdominal muscles, which causes a rapid and forcible 
expiration. The patient is unconscious of the scream, or he may be conscious 
of it, but unable to prevent it. 

In the fit, when of ordinary severity, consciousness is early lost, and it 
does not return until the somnolence which follows the attack has abated ; 
but in the mild disease, the petit mal, the patient, though confused, often 
retains consciousness during the attack. In the grand mal the attack begins 
with a tonic spasm of the muscles, causing rotation of the head and deviation 
of the eyes to one side. Sometimes there is rotation of the entire body, so 
that the patient turns round one or more times before he falls. The position 
of the limbs during the tonic spasm varies. Commonly the arms are slightly 
abducted, the forearms flexed to a right angle, the hands flexed on the wrists, 
the fingers flexed on the hands, but extended at the other joints, and the 
thumb is pressed upon the palm or fore finger. The legs are ordinarily 
extended, but the legs as well as arms may assume different positions. 

Clonic convulsions, or the second stage of the attack, supervene in a few 
seconds or after two or three minutes. As the tonic spasm slowly relaxes, 
the clonic spasms gradually supervene. The clonic convulsions, or alter- 
nate contraction and relaxation, rapidly succeeding each other, occur in the 
muscles of the face, tongue, palate, and larynx, as well as in the muscles of 
trunk and extremities. The tongue is frequently bitten, both in the tonic and 
clonic spasms, so that the blood oozes, and, mixed with frothy saliva, exudes 
from the mouth. The pupils are dilated during the attack, and they do not 
contract by light. As soon as consciousness begins to return, the pupils 
begin to contract and respond to light, Exceptionally, at the close of the 
fit the pupils alternately contract or dilate at intervals of one or two seconds, 
and, as already stated, the conjunctiva loses its sensitiveness, so that it can 
be touched without producing reflex action of the orbicularis. Relaxation 
of the sphincters also often occurs during the fit, so that fecal and urinary 
evacuations take place. 

The pulse may be normal or rather feeble in the beginning of the attack, 
but its frequency, and sometimes its fulness, increase during the muscular 
spasms. The features, usually pallid, but sometimes flushed at the beginning 



EPILEPSY. 627 

of the attack, become congested and even cyanotic in less than a minute. 
The congested and livid features present an alarming appearance, and fre- 
quentlv the general surface is bathed in perspiration before the attack ends. 
Ophthalmoscopic examination of the eyes during the convulsion is difficult, 
but during the cyanotic stage the retinal vessels have been seen presenting 
an engorged and dusky appearance. Gowers states that in one instance, in 
which fits occurred in rapid succession during several days, he observed con- 
gestion of the discs with slight oedema, which disappeared after the attacks 
ceased. In the intervals of the paroxysms nothing has been noticed in the 
appearance of the eyes which throws light on the nature of the disease. The 
duration of the second stage of an epileptic fit or that of clonic spasms varies 
from a minute or two to a considerably longer time. When it ceases the 
patient passes into a sleep or deep stupor, which continues a quarter of an 
hour or longer. If aroused from the stupor he complains of severe headache, 
and this continues often for hours after the stupor ceases. 

Languor and muscular weakness are common after the fit, and they grad- 
ually pass off. When, as occasionally happens, paralysis occurs after the fit, 
and continues for weeks or permanently, organic cerebral disease is present, 
either preceding and causing the fit or resulting from it. If no paralysis or 
cerebral symptoms have preceded a fit, and it is followed by paralysis of one 
or more of the extremities, it is highly probable that intracranial hemor- 
rhage has occurred during the attack. Todd, Hughlings Jackson, and others 
attribute the muscular weakness following an epileptic attack " to exhaustion 
of part of the brain by the excessive action," but protracted or permanent 
loss of muscular power in an epileptic having good general health indicates 
organic disease in the brain. 

The above description relates to epilepsy as it ordinarily occurs, but there 
are many cases which vary from the typical form. Tonic convulsions may 
occur without the clonic, and clonic convulsions without the tonic, and the 
convulsions, instead of being general, may be limited to a limb or to one 
region of the system. Of 155 cases of minor epilepsy, Growers states that 
in 45 the disease was indicated by momentary attacks of unconsciousness, 
faintness, or sleepiness ; in 25 by dizziness ; in 17 by sudden jerking of head, 
trunk, or limbs ; in 17 by loss or aberration of sight ; in 8 by a mental state, 
as sudden and extreme fright ; and in the remaining 42 by sensations of 
various kinds, or momentary rigidity, or by tremors or twitching occurring in 
some part of the system. Automatic movements sometimes occur during the 
stage of unconsciousness which succeeds the attack, and the attack may be 
so light that it is not noticed by the bystanders. Gowers relates several such 
instances. Some patients begin to undress themselves, whatever the sur- 
roundings ; others make the motions of walking up stairs, although no stairs 
are present ; some put in their pockets any near object, without regard to its 
nature or ownership. Trousseau states that an architect during the state of 
unconsciousness ran from plank to plank on the scaffold where he was at 
work, shouting his own name. One of Gowers's patients during the uncon- 
scious state laughed and sang ; another threw her infant down stairs ; a girl 
of twenty kissed every object within her reach ; and a man struck his friend 
a severe blow. Many supposed criminal acts have been perpetrated by un- 
conscious epileptics, for which they have been severely punished. 

Anatomical Characters. — No information has been obtained in regard 
to the etiology and nature of idiopathic epilepsy by a study of its anatomical 
characters. If the patient have died in the attack, intense venous conges- 
tion is observed of the cerebro-spinal axis as well as of other parts, but in 
recent cases nothing else abnormal has been detected in the brain or else- 
where. The thickening and opacity of the cerebral meninges sometimes 



628 LOCAL DISEASES. 

observed in chronic cases, and the induration of the pes hippocampi described 
by Meynert, are now believed to be results of the repeated attacks, and not 
their cause. Structural change in the brain in idiopathic epilepsy, if there 
be such, which sustains a causal relation to the attacks, has thus far eluded 
detection by the microscope. 

Pathology. — Epileptic attacks are believed by neuropathists to be due 
to a sudden and exaggerated functional activity of nerve-cells in some part 
of the brain. The theory at present accepted is that these cells generate a 
nerve-force which, transmitted along the nerves, stimulates the muscles to 
spasmodic contraction. In regard to the part of the brain in which these 
overacting cells reside, we may state that Brown-Sequard and Kussmaul 
demonstrated that convulsions may be produced by irritating the pons and 
medulla when every other part of the encephalon lying above these is 
removed. Convulsions can also be produced in acranial monsters, as I have 
stated above, by irritating the exposed medulla and pons. Nothnagel has 
also shown that there is a " convulsive centre " in the medulla oblongata. 
On the other hand, injuries of the convolutions more frequently cause con- 
vulsions than do those of any other part of the brain, and Wilks and others 
have taught that in ordinary epilepsy the part of the brain which is most 
frequently in fault, so as to cause convulsions, is the superficial portion or 
the convolutions. Still, the exaggerated production of nerve-force which 
causes the convulsions may be at a greater depth than the convolutions, 
even when the attacks are due to traumatism, since, as Burdon-Sanderson 
has shown, nerve-cells more deeply seated than the convolutions may be 
stimulated to increased functional activity by injuries of the superficial 
regions. Therefore, Nothnagel, aware of the fact that injuries of the cortex 
often cause convulsions, states that he sees no reason to modify his opinion 
that the exaggerated production of nerve-force which causes the convulsions 
is in the " convulsive centre in the medulla oblongata." The above observa- 
tions seem to indicate that epileptic attacks do in some instances originate in 
the convolutions or hemispheres, and in others in the medulla. 

Recently, (rowers and others have endeavored to determine in what part 
of the brain the nerve-force resides which causes the convulsions, by study- 
ing the aurse. Since the aurae have a central origin and are the first mani- 
festation of the exaggerated action of the nerve-cells, the attempt is made to 
determine the location of these cells by observing the nature and the seat 
of the aurae. Gowers says that one-fifth of the auras pertain to the special 
senses, and the nerve-centres of these senses " are certainly situated within 
the hemispheres, above the pons." Therefore, the inference is inevitable that 
in these cases the discharge of nerve-force which stimulates the muscles to 
spasmodic action is in the hemispheres. Moreover, a fit that is preceded by 
an emotional or mental aura, we infer, originates from the nerve-cells of the 
hemispheres which are the seat of the mind. The theory is therefore plausi- 
ble and apparently sustained by clinical observations, that in at least some 
instances the epileptic centre in the brain is in the hemispheres, though it 
may in other instances be at the base of the brain — in the medulla or pons. 

What occurs in the brain to produce the phenomena of epilepsy ? It is 
the belief of many specialists in nervous diseases that epilepsy results from 
suddenly developed cerebral anaemia produced by spasmodic contraction of 
the arterioles. It is also the belief of some that the primary discharge of 
nerve-force occurs in the medulla at the vaso-motor centre, and that this is 
followed by spasm of the arterioles in the hemispheres, by which conscious- 
ness is lost. That cerebral anaemia is present is inferred from the fact that 
the features are usually pallid when the attack commences. But in many 
instances, especially in epilepsy of a mild type, no pallor or other sign of 



EPILEPSY. 629 

peripheral anaemia is present, and in such cases there is no evidence what- 
ever of cerebral anaemia. Besides, as Gowers has forcibly stated, pallor of 
the features does not necessarily indicate cerebral anaemia, any more than 
flushing of the face indicates cerebral hyperemia. In experiments on frogs 
irritation of the brain causes contraction of the peripheral arterioles. Prob- 
ably in the same manner, says Growers, the contraction of the peripheral 
arterioles and the pallor result from the irritation of the brain, occurring in 
the first stage of the fit. That cerebral anaemia occurs in the attack, and 
that it sustains a causal relation to the phenomena of epilepsy, are assump- 
tions destitute of proof. 

As to the pathology of epilepsy, we have said or have intimated that it 
is the belief of the majority of those who from large clinical experience are 
most competent to express an opinion that the epileptic attacks are produced 
by a hyperactivity of nerve-cells in the gray matter in some part of the 
brain, and an increased discharge of nerve-force, which stimulates the mus- 
cles to spasmodic action. The spinal cord and the nerves are implicated as 
carriers of this nerve-force. Farther than this we are unable to express any 
theory in the present state of our knowledge. 

Diagnosis. — In a considerable number of instances nocturnal epilepsy 
is entirely overlooked. Some patients awaken at the beginning of the attack, 
and have subsequently a vague recollection of its occurrence. Others are 
aware of the fit by subsequent signs or symptoms, as a bitten tongue, blood 
on the bed-clothes, a swollen and ecchymotic face, conjunctival extravasation, 
and perhaps evacuations in the bed. In children nocturnal epilepsy is more 
likely to be detected than in adults, since they are more closely watched. 
Gowers states that he has known it to occur twenty years without being sus- 
pected. In mild epilepsy the symptoms may escape the notice of friends, 
and when observed by the patients and friends their import is often misun- 
derstood. Those suffering from petit mat are in many instances supposed to 
have attacks of faintness. The differential diagnosis between epileptic ver- 
tigo and syncopal faintness is made by the fact that in the latter the pre- 
vious health has usually been poor, the action of the heart feeble, and there 
is some exciting cause of the sudden cardiac weakness ; whereas in epileptic 
vertigo such conditions do not, as a rule, exist. In epileptic vertigo there is 
no premonition except the aura, which is momentary, and recovery or return 
to the normal state is rapid. Syncope, on the other hand, begins and ends 
in a more gradual manner. 

The symptoms of eclampsia and epilepsy are identical as regards the 
convulsive movements. We designate by the term " eclampsia " those attacks 
which are due to local or general causes, which do not recur when these 
causes are removed, and the occurrence of which, whatever the causes, is 
limited to a brief period. But, as we have seen, one attack of convulsions 
predisposes to another, and one or more convulsive fits that are eclamptic 
frequently establish the convulsive habit, so that epilepsy results. In a 
large proportion of the cases of eclampsia, the convulsions have a reflex 
origin. They are produced by causes located at a distance from the brain 
and affecting the nervous centres, causing convulsions through the medium 
of the nerves. Painful and swollen gums in dentition, constipation, irrita- 
ting ingesta, intestinal worms, scarlet fever, nephritis with albuminuria, are 
among the common causes of eclampsia. In recent convulsions, when such 
causes are present, the diagnosis of eclampsia will be proper in the great 
majority of instances, and the attacks will cease and not recur when the 
apparent causes are removed. Gowers regards rickets as a common cause of 
eclampsia in young children, and remarks that when this diathetic state is 
cured by " cod-liver oil and steel wine r ' the convulsions no longer occur ; 



630 LOCAL DLSEASES. 

but if proper treatment be not employed, if the rickets continue, and with 
it the frequent convulsive attacks, the epileptic habit may be established and 
epilepsy continue during the remainder of life. 

Prognosis. — Epilepsy is rarely fatal, although the symptoms are very 
appalling to one who has not previously witnessed an attack. Asphyxia has 
occasionally occurred by the patients falling into water during the fit. Even 
little depth of water with the face downward is sufficient to cause fatal 
obstruction to inspiration. Therefore, not a few epileptics die by drowning. 
If the patient roll upon the face during the fit, or vomit, he may be 
asphyxiated by the bed-clothes or by the entrance of particles of food into the 
larynx. 

The spontaneous cessation of the epileptic fits and spontaneous cure of 
epilepsy rarely occur, since each attack tends more strongly to establish the 
epileptic habit. Fortunately, since the therapeutic uses of the bromides have 
become known, epilepsy has frequently been cured. In infancy and childhood, 
in the majority of instances, epilepsy is rendered milder, so that the fits occur 
at longer intervals, even if entire cure be not effected. Moreover, the pros- 
pect of curing epilepsy is better in children than in adults, in accordance 
with the law that the shorter its duration and the fewer the attacks which 
have already occurred the more amenable it is to treatment. Epilepsy in 
which several days intervene between the attacks is, as might be expected, 
more likely to be benefited by treatment than when the attacks are frequent. 
If the mind be not perceptibly impaired, if the fits are uniformly severe, 
instead of some being severe and others mild, if they occur only during sleep 
or only during wakefulness, and if hemiplegia be absent, the prognosis is 
better than when the reverse is the case. In ordinary cases of epilepsy in 
childhood, the attacks immediately become less frequent by the bromide 
treatment. If a sufficient amount of the bromide be administered three 
times daily, months often elapse before a recurrence of the attack ; but if 
the remedy be discontinued after six months or a year in the belief that the 
patient is cured, a recurrence of the disease is probable. A patient cannot 
be pronounced cured until three years have elapsed without any symptoms. 

Treatment. — No mode of treating epilepsy which will effect an imme- 
diate cure has yet been discovered, nor is it probable that such success of 
treatment will ever be obtained. Cure is effected by treatment which dimin- 
ishes the hyperactivity of the nerve-cells that are in fault, and prevents the 
exaggerated production of nerve-force. Medicines designed to effect this 
object must be given daily for a prolonged period, since their use for a few 
days or weeks does not suffice to produce the desired change in the nerve- 
centre. 

Since the bromides have come into general use in the treatment of nervous 
diseases, the first place is universally accorded to them among the remedies 
for epilepsy. The bromides of potassium, sodium, ammonium, and lithium 
have probably nearly the same effect, but the potassium and sodium bromides 
are usually prescribed. No advantage results from the use of bromine or 
hydrobromic acid, even if it were safe and convenient, for it becomes a 
bromide as soon as it enters the alkaline blood (Gowers). All the bromides 
produce acne, but this can be prevented to a considerable extent by the 
simultaneous use of arsenic in small doses. The bromide should be given 
daily for weeks or months in the smallest dose which is found to arrest the 
fits or, if it do not entirely arrest them, produces the most decided effect upon 
them. If the fit occur at a certain hour, one daily dose, administered pre- 
viously, may suffice to prevent it, but usually it occurs irregularly, and a 
morning and evening dose or three daily doses are required. Bromism, 
indicated by a weak pulse, cold extremities, and mental and physical dulness, 



EPILEPSY. 631 

has never, according to my observations, seriously interfered with the treat- 
ment. During my connection with the children's class of the Bureau for 
the Relief of the Out-door Poor at Bellevue almost every week new cases 
of epilepsy have been presented for treatment, and it has seldom been neces- 
sary to discontinue the use of the bromide on account of bromism. A girl 
had her first attack of clonic convulsions at the age of four months. When 
she reached the age of three years and a few months she began to have 
attacks of the petit mat. manifested by pallor and an epigastric aura, followed 
by sleep lasting one or two hours. These attacks occurred at irregular inter- 
vals. In her fourth year she had measles and scarlet fever. In her seventh 
year she came under observation. A strict milk diet was ordered, and she 
took one teaspoonful in the morning and two at night of the following 
mixture : 

R. Sodii bromidi oiii ss l 

Aquae, ^ x vj. — Misce. 

The treatment was continued with scarcely an interruption during her 
seventh, eighth, and ninth years, with complete cure of the disease, and with 
bromism only on one occasion. Gowers, writing of adults, remarks that few 
patients can take more than one and a half drachms of the bromide daily 
without bromism. But, according to my observations, children can take 
larger proportionate doses than this without injury. Although prescribing 
the bromide of potassium daily for children of all ages during many years, I 
have seldom observed any ill effects which were clearly attributable to its use 
except the occurrence of acne. Bromism soon disappears when the dose of 
the bromide is diminished or its use is discontinued. In general, this medi- 
cine should be given twice or three times daily during as long a period as 
two years after the last paroxysm, without diminishing the dose which is 
found sufficient to cure the disease ; and, to make sure of a cure, it should 
be employed a third year in a gradually diminishing dose. In the case 
related above, the patient, a girl then at the age of nine years, had taken the 
bromide of sodium two years in two doses of thirteen and twenty-six grains 
with complete arrest of the attacks, when she had symptoms of bromism. 
The bromide was discontinued, and she remained well for some weeks, but 
finally she stated that the furniture at times seemed to move. Half the 
previous dose was now employed for a month or two, when it was discon- 
tinued, and she has remained well without medicine during the six or eight 
months which have since elapsed. In slight bromism during the first and 
second years of treatment it is usually better, I think, to diminish the dose 
of the bromide, but not to discontinue its use, and at the same time to 
employ a vegetable tonic with alcohol. In great cerebral depression due to 
the bromide, it is probably better to entirely discontinue its use for a time, 
even if convulsions occur. 

Occasionally, the bromide employed alone does not cure epilepsy. It may 
then be given in combination with another drug which is believed to exert 
some controlling influence upon the disease, as digitalis, belladonna, cannabis 
indica, or zinc. These remedies were prescribed with apparent benefit in 
certain instances before the bromides came into use. Digitalis has been 
employed as a remedy for epilepsy since Parkinson recommended it in 1640. 
It is not very efficient when used alone, but in some instances when given 
with the bromide it evidently increases the curative power of this agent. 
Gowers says : " In many cases attacks which continued on bromide only. 
ceased entirely on bromide and digitalis." He observed good results from 
the use of this combination, especially in epileptics who had cardiac disease, 
as dilatation, valvular insufficiency, hypertrophy, and a too rapid pulse. 



632 LOCAL DISEASES. 

Benefit also occurred in some instances in which the heart's action was nor- 
mal, as in the following case : Jesse . aged twelve years, was, when an 

infant, rachitic, backward in teething and the use of his limbs. He had the 
first epileptic fit at the age of sixteen months. The attacks occurred at 
intervals of one week, and were preceded by a visual aura, a red ball of fire, 
that approached the eye. Fifteen grains of the bromide of ammonium, with 
five minims of the tincture of belladonna, were prescribed, to be given twice, 
and subsequently three times, daily. With this treatment the intervals 
between the fits were lengthened to one month, but they still occurred after 
six months' treatment. Five minims of the tincture of digitalis were then 
substituted for the belladonna, and no fit occurred for eleven months. On 
diminishing the dose of digitalis one fit occurred, but on resuming its use in 
five-minim doses seven months elapsed without an attack. A girl of eighteen 
years had a convulsion at the age of two years, another at seven years, and 
confirmed epilepsy since her tenth year. The attacks occurred about every 
second day, without an aura. The bromide alone and bromide with bella- 
donna were employed, with slight diminution in the frequency of the attacks. 
Digitalis with the bromide was then employed. Immediately the fits were 
reduced to four, then to two, in the month, and then four months elapsed 
without a fit. A girl aged eleven years, greatly frightened by a thunder- 
storm, began to have nocturnal epileptic attacks. At the age of fourteen 
years, when treatment was commenced, the attacks occurred nearly every 
night. One scruple of the bromide of potassium and ten minims of tincture 
of belladonna reduced the attacks to one in ten days. Then the treatment 
was changed to two scruples of bromide of ammonium and five minims of 
tincture of digitalis, taken once daily at night, and two months passed with- 
out an attack, when she was lost sight of. These cases, to which more might 
be added, show that digitalis combined with the bromide increases the efficacy 
of the latter in certain cases. 

Belladonna has been employed in the treatment of epilepsy during the 
last two centuries. It was recommended by Mardorf in 1691, and by Hufe- 
land. Stoll. and others in the eighteenth century. Its proper use is in com- 
bination with one of the bromides, when the latter is inadequate to arrest the 
attacks. Used alone, it does not cure epilepsy, though occasionally it renders 
the attacks less frequent. But Growers relates cases which show that it 
increases the efficiency of the bromides in certain cases when combined with 
them. It is believed to first stimulate and then depress the functions of the 
nervous system, acting not upon one part only, but upon various parts of the 
brain and spinal cord, affecting their functional activity. To show the effect 
of the combination of belladonna with the bromide, Gowers relates the case 
of a boy in whom epilepsy commenced at the age of thirteen years without 
known cause. The attacks began usually in the morning without an aura, 
at intervals of three weeks. Fifteen grains of the bromide administered 
night and morning reduced the attacks to one a month. After three months 
of treatment twenty grains of the bromide and five minims of tincture of 
belladonna were given three times daily, and two months elapsed without an 
attack, when two occurred. Subsequently, he took the same medicine four- 
teen months without an attack, when treatment was discontinued. Six 
months later he was still well. Other cases have been related in which 
belladonna, combined with the bromide, produced a more decided curative 
action than the bromide employed alone ; but in some instances, as we have 
seen, when these two agents fail to cure, this result is accomplished by the 
bromide and digitalis. The liquor atropine, one minim of which contains 
t 4-q of a grain of atropine, may be used in place of the tincture of bella- 
donna. 



EPILEPSY. 633 

Stramonium, cannabis indica, and gelsemium sempervirens have been pre- 
scribed with some apparent benefit in certain instances, but it is the common 
belief with those who have employed them that they are no more efficacious 
than digitalis and belladonna, and they seldom if ever cure the disease when 
used alone. When employed with the bromide, good results have followed, 
but the improvement has probably been due almost entirely to the bromide. 

Zinc has been recommended in the treatment of epilepsy for more than a 
century by good observers. In experiments on animals it has been found to 
dimmish reflex action, and it exerts some controlling effect on the functions 
of the hemispheres and the medulla oblongata. It diminishes the frequency 
of the epileptic attacks in many patients, but not usually so certainly as the 
bromides, or to such an extent. In exceptional instances zinc prevents the 
epileptic attacks to a greater extent than the bromide, especially when they 
present the hy steroid form. The oxide, lactate, and citrate are commonly 
prescribed, and a child of eight years can take from one to two grains three 
times daily. It should be given after the meals, since it sometimes irritates 
the stomach and causes nausea. It is believed by Gowers to be slowly con- 
verted into the chloride in the stomach. He relates the case of an adult 
epileptic who took five grains of the oxide of zinc morning and evening, and 
had no attack during the five months in which he was under observation. A 
girl of eight years having inherited epilepsy, after four months of treatment 
with the bromide was still having two fits each week. Oxide of zinc in 
doses of three grains was ordered, and in two months the fits ceased. Nine 
months elapsed with only one attack, when the patient was lost sight of. 
Gowers also relates the following case, showing that the addition of the zinc 
to the bromide sometimes plainly increases the efficiency of the latter: A 
boy of eleven months, belonging to an epileptic family, had a fit at the age 
of eleven months. At the age of fourteen years, when he was presented for 
treatment, the convulsions occurred every two weeks. One scruple of bro- 
mide of ammonium administered three times daily caused some improvement, 
as did the bromide with digitalis, but the disease was not cured until the 
zinc was employed with the bromide. In obstinate cases, therefore, zinc is 
sometimes useful as an adjuvant to the bromide. 

Opium, or its alkaloid morphia, has been long employed in the treatment 
of epilepsy, but its use has now given place, for the most part, to that of 
other remedies. Occasionally, especially in the hysteroid forms of epilepsy, 
morphia given at the commencement of the warning has apparently pre- 
vented the fit. 

The effect of iron in epilepsy is equivocal and uncertain. Brown-Sequard 
and Jackson discountenance its use, and they think it increases the frequency 
of the attacks. Gowers says that he has given iron to several hundred 
epileptics, and that it only rarely increases the severity of the fits. In most 
instances it produces no ill effect, and it sometimes improves the general 
health. He states that occasionally bromide with iron arrests the attacks, 
when the bromide alone has little effect. 

A considerable number of remedies which we have not mentioned have 
been employed, but they have been for the most part discarded by recent 
observers, either because they have been found to be inert or have been use- 
ful only in rare cases, and less useful than other remedies. 

According to my observation, the treatment which has been found ade- 
quate to arrest the fits should be continued at least two years after the last 
paroxysm, being omitted for a few days or its quantity reduced if symptoms 
of bromism occur. Even after a cure for two years occasional symptoms of 
the petit mod may occur, so that it will be necessary to resume the use of the 
medicine in smaller doses. 



634 LOCAL DISEASES. 

Hygienic Treatment. — It is necessary that an epileptic child should lead a 
quiet and regular life, free from excitement and all perturbating influences. 
The diet should be plain and easily digested. In some instances a diet con- 
sisting almost entirely of milk has seemed to be a very important remedial 
measure. 



CHAPTEK IX. 

INTERNAL CONVULSIONS (SPASM OF THE GLOTTIS ; LARYN- 
GISMUS STRIDULUS). 

Young children are liable to temporary suspension of respiration, induced 
by violent emotions, especially by anger. In the midst of their excitement, 
while they are crying or screaming, their breath is suddenly held, as if from 
tonic spasm of the respiratory muscles. In a few seconds respiration returns 
and is natural. There is no stridulous inspiration or other unusual sound, 
and there is no apparent ill-effect, unless occasionally a degree of languor. 
External convulsions, which seem to be threatening, seldom occur, and when 
they do are ordinarily mild. Some writers consider dentition the predispos- 
ing cause of this arrest of respiration by inducing a sensitive state of the 
nervous system ; such an effect is possible, but certainly many infants are 
affected in this manner before the age of dentition. 

A much more serious state, and one which is recognized as a true disease, 
is that variously designated by writers as internal convulsions, spasm of the 
glottis, child-crowing, laryngismus stridulus, etc. Manifest difficulties attend 
the investigation of the pathological state in this disease. There can be 
little doubt that it is not precisely the same in all cases. That there is, dur- 
ing the paroxysms, tonic or clonic spasm of more or fewer of the respiratory 
muscles is inferred not only from the symptoms pertaining to the respiratory 
apparatus, but from the fact that in severe cases spasms of the external 
muscles, as those of the limbs and face, often occur. L T sually, also, the 
movements of the eyeballs indicate spasmodic contractions of the motor mus- 
cles of the eyes. The fact of spasmodic muscular action in parts that are 
visible justifies the belief that it occurs in other parts which are concealed 
from view, especially as the characteristic symptoms cannot be readily ex- 
plained except on this supposition. Trousseau says : " Internal convulsions 
consist, then, principally in a spasm of the diaphragm and of the respiratory 
muscles of the abdomen and chest ; but it occurs also that the muscles per- 
taining to the larynx are affected with spasm at the same time with these." 
Rilliet and Barthez conclude from the symptoms that the " heart is not 
always a stranger to this internal convulsion, which perhaps prolongs itself 
even to the intestines." The muscles of the pharynx appear to be involved 
in some cases, as well as those of respiration, rendering deglutition difficult. 
In one form of internal convulsions — namely, that which is principally 
referred to by writers — there is not complete arrest of respiration, but the 
inspirations during the paroxysms are difficult and are attended by a stridu- 
lous noise. Again, the respiration may cease entirely, but when it com- 
mences it is stridulous and difficult during a few inspirations. In still 
another form of the disease respiration ceases, but there is no symptom or 
sign indicative of glottic spasm or of an obstacle to the ingress of air ; the 
inspirations which succeed the paroxysm are easy and noiseless. It has been 
suggested that in these cases there is paralysis rather than spasmodic con- 



INTERNAL CONVULSIONS. 635 

traction of the respiratory muscles ; but the symptoms may be explained in 
accordance with the commonly accepted opinion — namely, that there is spasm 
of the diaphragm and perhaps of certain muscles of the chest and abdomen, 
while the laryngeal muscles are not affected. M. Herard, indeed, who has 
written one o*f the best monographs on internal convulsions, describes three 
forms of the disease according to the supposed location of the spasm — - 
namely, laryngeal, diaphragmatic, and another which consists of a blending 
of the two. 

Internal convulsions are not frequent in this country ; they are rare in 
France, more frequent in Germany, and quite common in England. They 
occur, with few exceptions, before the age of two years. Dr. West observed 
31 cases under the age of two years, and only 6 above that age. The fact 
has been established by many observations that the rachitic are especially 
liable to spasm of the glottis. 

Causes. — Spasm of the glottis has been attributed to enlargement of the 
thymus gland, and also to enlargement of the cervical and bronchial glands. 
It is presumed that this effect is due to the pressure of these glands on the 
par vagum or the recurrent laryngeal nerve. It is certain, however, that 
there is no such enlargement of the thymus gland which could possibly pro- 
duce glottic spasm or any other form of internal convulsion at the age at 
which these convulsions commonly occur. This gland is largest in the new- 
born, and, having no function after birth, it gradually becomes atrophied. If 
an enlarged thymus could produce glottic spasm, it would certainly occur 
most frequently in the new-born. Abnormal development of the thymus 
gland seemed to be the cause of atelectasis in two infants who died soon after 
birth in my practice, but I have not seen a case in which a convulsive attack 
was referable to this cause. M. Herard examined the thymus gland in 6 chil- 
dren who died of internal convulsions and in 60 who died of other affections, 
and was not able to discover in its condition any causal relation to this dis- 
ease. Indeed, cases have been reported in which the thymus had undergone 
more than its usual atrophy at the time when the convulsions occurred 
(Haase). Enlargement of the lymphatic glands in the vicinity of the pneu- 
mogastric or recurrent laryngeal nerve may possibly give rise to glottic spasm, 
but this is doubtless an infrequent cause, if it be a cause at all, since these 
glands are often greatly enlarged in strumous and tubercular diseases without 
such a result. 

The cause is occasionally located in the cerebro-spinal axis. Thus, Dr. 
Coley relates a case in which an exostosis arising from the internal surface 
of the occipital bone pressed upon the cerebellum, while nothing abnormal 
was discovered in other organs. Examples are also related in which the 
cause was located in the spinal cord. Thus, Marshall Hall relates the case 
of a child with spina bifida who was attacked with croup-like convulsions 
whenever it lay so as to press on the tumor. 

Internal convulsions are also frequent in rachitic softening and absorption 
of the calvarium, since, when this is present, undue pressure occurs upon the 
brain by the weight of the head of the child upon the pillow. 

In some patients there is evidently an hereditary predisposition to this 
disease, those affected belonging to families in which a tendency to convul- 
sive maladies is manifested. Thus, Toogood states that five infants of the 
same family were affected with spasm of the glottis ; and Reid relates, on 
the authority of Powel, that of thirteen infants of the same parents only 
one escaped internal convulsions. 

The common predisposing cause is an excitable state of the nervous sys- 
tem, often associated with impaired general health. Hence the disease is 
more prevalent in cities, where antihygienic conditions abound, than in the 



636 LOCAL DISEASES. 

country. Hence, too, the frequent improvement when the patient is removed 
to the pure and bracing air of the country. The use of insufficient food or 
food of a bad quality must for the same reason be considered a cause, since 
it leads to impoverishment of the blood and renders the nervous system more 
impressible. Facts mentioned by Reid and others show conclusively the influ- 
ence of premature weaning and the use of indigestible or otherwise improper 
aliment in the production of this disease. 

The causes enumerated above are for the most part predisposing ; occa- 
sionally they are the only apparent causes, since this disease sometimes occurs 
when the child is tranquil, even in the midst of quiet sleep or when it is at 
rest in its mother's arms. In other cases and more frequently there is an 
exciting cause, often trivial. Anything that requires exertion on the part 
of the infant or that excites strong emotions may be a direct cause, as anger 
or any of the violent passions : so may even coughing, or, in rare instances, 
attempts to swallow. One author has known it to occur from excitement 
produced by examinigg the throat with a spoon. In a case in my practice, 
hereafter related, it occurred whenever the infant cried violently. It appears 
from the above facts that the etiology of internal convulsions is very similar 
to that of eclampsia. The same spasmodic muscular contraction may occur 
from a variety of causes. 

Anatomical Characters. — While, therefore, structural changes in 
various parts of the system may give rise to internal convulsions, this dis- 
ease, so far as ascertained, presents no anatomical characters, and must conse- 
quently be considered one of the neuroses. The lesions of the respiratory 
apparatus which are seen at post-mortem examinations are due to the convul- 
sions or are coincidences. Emphysema has sometimes been observed as a 
result, it is believed, of the spasmodic and irregular respiration. It was pres- 
ent in all of Herard's cases, and Rilliet and Barthez consider it common in 
those who die of this affection, although they did not observe it in any of 
their cases. Slight emphysema in the upper lobes is, however, a common 
lesion in feeble infants, whatever the diseases of which they die. Therefore 
its occurrence in internal convulsions is probably due more to molecular 
change in the lungs, since these patients are cachectic, than to the irregular 
breathing, which is only momentary. 

In fatal cases of internal convulsions the blood is darker than usual, from 
an excess of carbonic acid ; and in some cases the cavities of the heart and 
large vessels are engorged with blood, but in others they contain no more 
than the normal amount. More or less passive congestion occurs in the inter- 
nal organs ; and congestion of the cerebral vessels is in some patients so great 
that transudation of serum occurs. 

Symptoms. — I have said that the symptoms vary according to the seat 
and function of the muscles which are affected. There is generally previous 
ill-health. The child is drooping, and is sometimes restless, for days before 
the disease appears. Finally, if the muscles of the glottis become affected, 
the peculiar crowing sound is heard now and then during inspiration. It is 
observed especially when the child is crying or is agitated. It may be loud 
and well defined from the first, but in most patients it comes on gradually, 
so that several days elapse before its full stridulous character is developed. 
The attacks are more frequent and severe at night, in or after the first sleep, 
than in day-time. 

Under favorable hygienic conditions the malady may pass off without 
becoming more serious. In other cases the paroxysms gradually increase 
in frequency and severity. The dyspnoea in the attack is such that the 
features are livid, the head forcibly retracted, and death seems imminent 
from apnoea. In these severe paroxysms respiration often ceases entirely for 



INTERNAL CONVULSIONS. 637 

a moment. When the spasm ends a deep stridulous inspiration occurs, after 
which the breathing is natural. I have stated also that internal convulsions 
are often associated with those — usually tonic, but sometimes clonic — of the 
external muscles. In the tonic form the thumbs are flexed across the palms 
of the hands, and sometimes are grasped by the fingers ; the great toes are 
adducted and the other toes flexed. In severe cases the hands, forearms, feet, 
and legs are also somewhat flexed and rigid. At first the contraction of the 
external muscles is temporary, either corresponding with the internal spasm, 
or it is most intense at the time of the spasm, though commencing sooner 
and subsiding later. After a while, however, if the disease continue, the 
spasmodic action of the external muscles becomes more persistent. In severe 
cases nearly every inspiration is accompanied by the whizzing sound, and 
the paroxysms of dyspnoea are excited by trifling causes. Anything that 
suddenly disturbs the mind or body may bring on the attack, as anger, the 
impression of cold, or currents of air. Dr. West calls attention to the fact that 
an anasarcous condition is sometimes present, accompanied by albuminuria. 

If the convulsions affect other muscles, as the diaphragm or the pectoral 
and abdominal muscles, which are concerned in the respiratory function, 
while those of the larynx escape, respiration is irregular or even suspended 
for a moment, but the stridulous laryngeal sound is absent, as there is in 
the larynx no obstacle to the entrance of air. In this form of the disease the 
inframammary region may be strongly retracted during the paroxysm from 
tonic contraction of the diaphragm. In severe paroxysms, whether the spasm 
be laryngeal or diaphragmatic, consciousness is nearly or quite lost, the 
features may be pallid, or, if respiration be suspended, may be more or 
less livid. Relaxation of the sphincters of the bowels and bladder, with 
involuntary evacuations, often occurs in this disease during the attack. 

The duration of the paroxysm may be a quarter, a half, or even a whole 
minute. Total suspension of respiration for even half a minute involves 
danger. In mild cases there may be but few paroxysms, and these slight. 
In other instances they occur in a severe form almost daily for several weeks 
or even months. 

The general health in internal convulsions is more or less impaired, except 
in mild forms of the disease, in which the convulsive attacks soon cease. 
Pallor or a sickly and cachectic aspect, irregular, usually constipated bowels, 
poor appetite, and moroseness or irritability of temper are common symptoms 
of severe and protracted cases. 

Diagnosis. — This disease is easily diagnosticated, unless when its symp- 
toms are masked by those of external convulsions ; it may then escape notice. 
Spasm of the glottis may be mistaken for spasmodic laryngitis, and vice versa. 
In some of the published cases this mistake appears to have been made. 
Spasmodic laryngitis is, however, so different not only in its nature, but in 
its clinical history, that a differential diagnosis is not difficult. It is an 
inflammatory disease, and is attended with feeble reaction and a sonorous 
cough ; it commences at night after the first sleep and from exposure to 
cold — particulars in regard to which it contrasts with true spasm of the 
glottis, which in complicated cases is not attended by any febrile symptoms. 

Prognosis ; Modes of Death.— Statistics show great mortality in this 
disease. Dr. Reid, in a monograph on " Infantile Laryngismus," states that 
of 289 cases which he collated, 115 died. Rilliet and Barthez met with 1 
favorable case in 9 unfavorable, and Herard 1 in 7. If the paroxysms be 
mild, infrequent, and dependent on a cause which can be easily removed, 
recovery is probable with proper treatment. The cause may, however, be 
such, even when the spasm is mild, that the case is necessarily unfavorable, 
as when it is due to disease of the cerebro-spinal axis. We should, not. how- 



638 LOCAL DLSEASES. 

ever, in any case consider the patient entirely safe, since grave symptoms 
may suddenly arise, so as to change entirely the prognosis. Long and severe 
paroxysms, with lividity of face and symptoms of suffocation, indicate an 
unfavorable result. The same should be predicted also if the infant gradually 
lose flesh and strength, especially if the face be pallid, the pulse feeble, and 
the appetite poor. 

There are three modes of death in internal convulsions. The first is by 
apncea. The infant dies suffocated in the attack. Respiration is first arrested, 
and then the pulse ceases, and at the autopsy the lungs and the cavities of the 
heart are found engorged with dark blood. Death may also result from the 
state of the brain. In such cases passive congestion of the brain occurs from 
obstruction to the return of blood from this organ to the heart and lungs ; 
and if this congestion be not soon relieved serous effusion also occurs. Death 
results from the congestion and consequent cedema or dropsy. 

The third mode of death is from exhaustion. Repeated and severe attacks 
undermine the constitution ; the infant gradually grows pallid and thin, and 
dies of inanition or of some disease which this state induces. 

Treatment. — The treatment of internal convulsions has varied according 
to the theories which physicians have held in reference to its cause. Gland- 
ular enlargement is no longer regarded as a common cause, and therefore 
treatment directed to its removal is less frequently prescribed than formerly. 
The causes of internal convulsions are in part very similar to those of eclamp- 
sia, and the remedies employed in the one affection are, in a measure, appro- 
priate in the other. That dentition is sometimes a cause is usually admitted, 
and two cases, one of which occurred in my practice and the other was reported 
to me, appeared to show that it may operate as a cause. The effect of 
dentition is especially observed in weakly infants when several dental fol- 
licles are undergoing active evolution. Thus, in one of the cases to which I 
refer five teeth pierced the gums in the course of two weeks ; after which no 
convulsive attack occurred. If, therefore, the gums are swollen, the propriety 
of scarification should be considered, especially if the convulsions be so severe 
as to endanger life. 

In all cases of internal convulsions a careful examination should be made 
in order to detect any aberration from the normal state .which might cause 
nervous excitation. The condition of the digestive organs should be ascer- 
tained, and evacuants or other remedies prescribed if there be evidence of 
their derangement. 

Sometimes the alimentation of the infant is at fault. It is perhaps bot- 
tle-fed and the stools have an unhealthy appearance. Attention should be 
given to the preparation of its food and the times of its feeding, or if it 
nurse the mother or wet-nurse who suckles it should have plain but nutri- 
tious diet, live with regularity, and give the breast to the infant at regular 
intervals. If there be a torpid state of the intestines, Dr. Meigs recommends 
' : castor oil and aromatic syrup of rhubarb rubbed up together, three parts of 
the former and five of the latter." A simple enema answers well in such 
cases, and in debilitated infants this is preferable to medicine administered 
by the mouth. If diarrhoea be present, and it persist after the requisite 
changes are made in regard to the diet, remedies calculated to relieve it, 
which are mentioned elsewhere, should be employed. Marshall Hall states 
that he has ordinarily succeeded in curing the disease by attending to the 
condition of the gums and digestive organs. 

Since rachitis is a not uncommon cause, the child should be examined in 
reference to rachitic manifestations, and if they appear the treatment appro- 
priate for rachitis is required. 

In pallid and cachectic infants tonics are indicated. The elixir of cali- 



INTERNAL CONVULSIONS. 639 

saya-bark with iron, in half-teaspoonful doses three or four times daily to an 
infant of two years, is an eligible preparation. The preparations of iron are 
frequently to be preferred to the vegetable tonics, as the citrate of iron and 
bismuth, citrate of iron and quinia, the syrup of iodide of iron, or the wine 
of iron. To an infant of one year the syrup may be given in doses of three 
drops, the citrates in one-grain doses, and the wine in doses of one teaspoonful, 
every four hoars, or the liquor ferri peptonati may be employed. 

Antispasmodics, as asafoetida, valerian, and oxide of zinc, are often pre- 
scribed in this malady, but they are less efficacious than the general tonic 
measures which I have mentioned. The salutary effect of bromide of potas- 
sium in eclampsia and epilepsy certainly justifies the trial of this agent in 
internal convulsions if they persist after the employment of invigorating 
remedies. 

Hygienic measures are of the utmost importance. The infant should 
reside in dry and airy apartments, and should be kept much of the time 
through the day in the open air. Remarkable success sometimes attends 
this simple expedient when medicines have entirely failed. Mr. Robertson l 
of Manchester relates five severe cases in which this disease was cured by 
exposure of the infants several hours daily to a cool atmosphere. These 
cases were treated in the winter months, and were kept outdoor even during 
strong winds. Mr. Robertson has records of forty cases, all occurring 
between December and April, while he has seen no case in the summer 
months. As the result of such extensive experience the writer recommends 
" the free exposure of the infant out of doors for many hours daily to a dry, 
cold atmosphere, and, if the air be dry, the colder the better." Dr. Marshall 
Hall's experience was similar. Says he : " The curative influence of the air, 
and especially of the sea-breezes, is not less marked in this affection than in 
whooping cough." Mr. Robertson recommends also, as part of the tonic 
treatment, " free sponging of the body every morning with cold water." In 
February, 1867, I attended a nursing infant five months old with internal con- 
vulsions, the paroxysms being attended with lividity of the face and at times 
tonic convulsions of the limbs. Among the remedies employed was bromide 
of potassium, but more benefit obviously accrued from keeping the infant 
much of the time in the open air than from the medicines employed. The 
disease passed off in six or eight weeks. 

Unless the cause be of such nature that it cannot be removed, the above 
hygienic and therapeutic measures will, in a large proportion of cases, be fol- 
lowed by a satisfactory result. 

The mother or nurse may abridge the paroxysm by raising the infant, 
blowing upon it, sprinkling water in the face, or gently stroking it. Dr. 
Hall recommends tickling the nostrils with a feather to produce respiration, 
or the fauces to occasion vomiting, and thereby interrupt the paroxysm. 
Anything which causes a sudden and profound effect upon the system 
may abridge the attack. This was effected in one case in the practice of 
Dr. C. C. Meigs by applying a cloth wrapped around ice over the epigas- 
trium and the lower part of the sternum. The chief danger during the 
attack is from congestion of the brain, with effusion of serum or extravasa- 
tion of blood. If the attack be severe and the features congested, so that 
there is evident danger of such a result, cold applications should be made to 
the head, derivatives applied to the extremities — as sinapisms or mustard 
foot-baths — and the bowels should be speedily opened by enemata. 

1 London Med. Gazette, Jan. 14, 1865. 



640 LOCAL DISEASES. 

CHAPTER X. 
TETANY. 

The disease known as tetany has probably always existed, for its recog- 
nized causes are of common occurrence, but the attention of the profession 
was first directed to it by a memoir bearing the title " Observations sur une 
Espece de Tetanos intermittent," published by M. Dance in the Archives 
generates de Medecine in 1831. He described it as it occurs in the adult. In 
the following year (1832) M. Tonnele published in the Gazette medicale an 
essay on tetany, which he designated a new convulsive disease of childhood. 
In the same year Constant and Murdoch also published their observations on. 
this malady in French medical journals, the former designating it ,; Contrac- 
tures essentielles," and the latter '• Retractions musculaires et spasmodiques." 
In 1835 the memoir of De la Berge on tetany, bearing the title " Retractions 
musculaires de courte duree," was published in the Journal Hebdomadaire. 
From this time the disease was fully recognized in France, and several addi- 
tional monographs relating to it appeared in medical journals prior to 1850, 
among the most notable of which was the thesis of Delpech in 1846. The 
term tetany (tetanie) was first employed by Dr. Lucien Corvisart in an 
interesting and instructive paper published in 1851. 

The term tetany is applied to a disease which is characterized by tonic 
contraction of muscles, commonly those of the extremities, but sometimes 
also those of the face or trunk, produced by causes external to the nervous 
system, and usually of temporary duration. The exception to this definition 
might be as regards such causes as are psychical or emotional, if such exist. 
Following this definition, we would exclude cases of tonic muscular contrac- 
tion, however close the resemblance, which arise from disease of the brain r 
spinal cord, or their meninges, or from disease of the nerve supplying the 
affected muscle. The contractions in these cases are not the malady itself, 
as in tetany, but are merely symptoms of some important disease located in 
the nervous system at a distance from the affected muscles. 

Causes. — Tetany may occur at any age, but is most frequent in infancy, 
in early childhood, and in early adult life. Of 28 cases observed by Rilliet 
and Barthez, 1 was at the age of nine months, 13 between the ages of three 
and fifteen years, 5 at the age of three years, and the remaining between the 
ages of three and fifteen years. Eustace Smith says that the period during 
which the largest number of cases occur is between the first and third years. 
In 142 cases collated by Gowers the ages were as follows : Between one and 
four years, 34 ; between fory and nine years, 8 ; between nine and nineteen 
years, 36 : between nineteen and twenty-nine years, 24 ; between twenty- 
nine and thirty-nine years, 23 ; between thirty-nine and forty-nine years, 13 ; 
and between forty-nine and sixty-one years, 4. Erb remarks that a strong 
tendency to tetany is exhibited in early childhood, and the next most common 
period of its occurrence is at the age of puberty and early youth. The statis- 
tics of different observers show that tetany is more common in males than 
females. Of Rilliet and Barthez's 28 cases. 20 were boys. Of the 142 cases 
embraced in the statistics of Gowers, 76 were males and 66 females. Accord- 
ing to Gowers, in the first and second decades, in which a large majority of 
the cases occur, more males are affected than females, but between the ages 
of twenty and fifty years, females preponderate, while above the age of fifty 
years all the recorded cases have been males. It is seldom that the most 
thorough investigation elicits any inherited predisposition in cases of tetany 



TETANY. 641 

to nervous or other diseases. Most of the observed cases have occurred 
singly in families, and in families which exhibit no special tendency to 
nervous or other ailments. Rarely, however, multiple cases have occurred 
in families, from which we infer that there may be an inherited neuropathic 
tendency. The only instances of this sort which I have been able to find in 
the literature of tetan}^ were two cases observed by Murdoch in one family, 
and cases alluded to by Abercrombie, who states that at different times 4 
cases occurred in each of two families, and 2 cases in another family. 

Although in many instances different causes appear to act simultaneously 
in causing tetany, nearly all writers who have contributed to the literature 
of this malady assign the most important place in the causation to diseases 
of the digestive apparatus. Trousseau states that in the cases which have 
fallen under his observation diarrhoea has been commonly present. He says 
that in 1854 he met many cases following cholera, but in one instance occur- 
ring in his practice the cause seemed to be obstinate constipation. The 
patient at the age of seventeen years was suddenly seized when travelling. 
His fingers were bent and he could not extend or use them. The tetany 
subsided in two or three hours, but it recurred every day for three months. 
He was treated by bleedings, but the tetany was uniformly worse after each 
loss of blood, the contractions becoming more severe and also more general. 
Not only were the muscles of the extremities in a state of tetanic contrac- 
tion, but also those of the face and trunk, so that respiration and speech 
were embarrassed. Although the contractions were aggravated by bleeding, 
and were never so bad as after the fourth venesection, they ceased entirely 
for a period of ten months after cupping along the spine. Subsequently 
they recurred every year at the close of winter and continued two months. 
The patient was habitually constipated, and the torpid state of the bowels 
seemed to be the chief factor in producing the tetany. In the following 
case, which I have recently had under observation, constipation appears also 

to have been the chief cause : George C , without teeth and at the age 

of seven months when tetany commenced, was taken from the breast at the 
age of two months. He lives in a tenement-house, and from the time of 
weaning has been fed with condensed milk, one heaped teaspoonful of large 
size to fifty of water. Besides this, he has taken once daily a tablespoonful 
of Nestle's food in ten of water. With this diet his growth has been about 
like the average, but he has been habitually very constipated, so as frequently 
to require assistance in obtaining an evacuation. Recently, groups of muscles 
in all the extremities have undergone tonic contraction, producing deformities, 
as shown in the photograph (Fig. 190), and brief attacks of laryngismus 
stridulus. These attacks of spasm of the glottis occur both by day and by 
night, causing for a moment the characteristic stridulous respiration. The 
mother states that at times he is feverish, probably from the constipation, 
but usually he seems entirely well, except as regards the sluggish state of 
the bowels and the contractions. Attempts to straighten the fingers and toes 
elicit cries from the pain. The mother also says that at times both thighs 
and both legs are flexed, and he resists attempts to straighten them on 
account of the pain. The treatment employed consisted in the use of bro- 
mide of potassium and measures designed to relieve the constipation. When 
these remedies were perseveringly employed, the contractions gradually 
diminished and ceased, but they returned when the treatment was discon- 
tinued. Four months have elapsed since the commencement of the disease, 
and it is only in the last week or two that the contractions have entirely 
ceased. The important factor in producing the tetany in this case appears 
to have been the habitual constipation. One tooth pierced the gum during 
the four months of tetany. 

41 



642 



LOCAL DISEASES. 



Erb says that all forms of intestinal diseases may cause tetany, but it 
especially occurs after " protracted and exhausting diarrhoea." Gowers also 
remarks that .the most common cause of tetany is diarrhoea, usually long- 

Fig. 190. 




Photograph of a child, showing tonic contraction of groups of muscles of the extremities as 

the result of tetany. 

continued and exhausting, but sometimes acute and brief." Among the rarer 
intestinal causes of tetany may be mentioned the presence of worms. I 
have not found in the literature of tetany any instance in which lumbrici or 
ascarides caused the contractions, but Growers alludes to three cases in which 
they were produced by the tape-worm. 

From the nature of tetany, and from the important part long assigned to 
dentition in producing nervous ailments, it is perhaps remarkable that the 
teething process has so seldom been regarded as a factor in causing tetany in 
young children. But, so far as I have been able to learn from memoirs and 
recorded cases, those who have made special study of tetany agree for the 
most part with Trousseau, who says that in nearly all instances pathological 
conditions distinct from dentition are present, " on which tetany would seem 
rather to depend." Nevertheless, in the following case which was treated by 
Professor E. G. Janeway and myself, after repeated and thorough examina- 
tions, teething was regarded by both of us as the chief cause of the contrac- 
tions : 



Case.— B- 



aged twenty months, well-nourished, has during the last few 



days been unable to use the left lower extremity. The thigh is flexed at an angle 
of about forty-five degrees and the leg at about the same angle, and attempts to 
overcome the rigidity of the flexors and straighten the limb are resisted and are 



TETANY. 643 

painful. The muscles in the other extremities, and those which move the foot and 
toes of the affected limb, appear to have their normal functional activity, as do 
those of the face, neck, and trunk. The gums were swollen and congested over 
the crowns of five advancing teeth, which appeared to be in nearly the same stage 
of development, and were evidently soon to protrude. It is possible that a rather 
sluggish state of the bowels may have been a factor in causing the tetany, but the 
chief agent was apparently the cutting of so many teeth. There was not at any 
time any notable elevation of temperature, loss of appetite, or derangement of the 
functions of important organs, but the contractions continued three weeks, when 
all or nearly all the imprisoned teeth escaped and the limb was quickly restored 
to its normal state. There has been after the lapse of two years no return of the 
tetany. 

Tetany is more liable to occur in those whose systems are enervated by 
pre-existing disease than in those who are robust. Billiet and Barthez state 
that in cases which have come under their observation the patients were often 
in poor health, resulting from disease which they had had, as pneumonia, 
bronchitis, or enteritis. Bouchut also remarks that tetany occurs as a sequel 
of various enervating maladies, among which he enumerates cholera, typhus 
and typhoid fevers, and dysentery. Erb mentions the following diseases 
which sustain a causal relation to tetany or in the convalescence from which 
tetany is liable to occur : typhoid fever, measles, cholera, Bright' s disease, 
febris intermittens, in addition to the diarrhceal maladies which have been 
alluded to above. Eustace Smith goes farther, and states that tetany is rare 
in robust subjects — that it ordinarily occurs in those who have delicate con- 
stitutions by inheritance or disease or are imperfectly nourished. Gowers, 
enumerating the maladies which are followed by tetany, mentions " typhoid 
fever, cholera, smallpox, rheumatic fever, measles, febricula, catarrh, and 
pneumonia ; " and he states also that in young children the indications of 
rachitis are rarely absent. 

Another recognized cause of tetany is taking cold. Exposure to wet and 
cold has in numerous instances been followed by tetany. From this mode of 
origin the opinion arose that tetany is a rheumatic affection. Hence, Eisen- 
mann applied to it the term " brachiotonus rheumaticus," and Benedict desig- 
nated it •• rheumatische contractus " Erb says : "Amongst the exciting causes, 
catching cold is both the most important and the most common ; and this 
statement," he adds, "is supported by the fact that many physicians have 
regarded it as an exquisite example of rheumatic disease. Working in the 
wet or cold or in water, sleeping on the damp ground, have very often been 
regarded as causes, and the swelling in the joints which occurs in many 
instances indicates that this disease has a somewhat close relation to true 
rheumatism." It must be recollected that Erb's observations have been 
chiefly with adults. As regards infancy and early childhood, other causes 
of tetany are apparently more common than taking cold. Adults with 
tetany often attribute the attack to exposure in wet and inclement weather, 
and probably correctly. At the present time, in Charity Hospital, a female 
aged thirty-nine years is under treatment for tetany. She said that her sick- 
ness was produced by exposure in wet and cold weather. She was employed 
as a seamstress, and, being insufficiently clothed, sat at her work with feet 
chilled and wet. At the same time her menstruation had been irregular, and 
she had diarrhoea, apparently produced by the exposure. Tonic contractions 
occurred in the muscles of the fingers and toes on both sides, accompanied 
by pain, especially in the affected muscles of the lower extremities. Several 
months have elapsed since the commencement of the disease, and the fingers 
have regained nearly or quite their normal state, but the toes are firmly 
flexed. The chief cause of the tetany in this case appeared to be taking- 
cold, from which probably the diarrhoea resulted, which, as we have seen, is 



644 LOCAL DISEASES. 

one of the most common causes of the tonic contractions. Trousseau also 
relates cases in which exposure to cold was apparently the exciting cause. 
Growers states that next to diarrhoea the most common causes are " exposure 
to cold, acute disease, and lactation." 

Among the other recognized causes of tetany we may mention suckling, 
pregnancy, and the development at the time of commencing puberty. The 
first cases seen by Trousseau in Necker Hospital occurred in women recently 
confined who were wet-nursing, so that at first he designated the disease 
rheumatic contraction occurring in nurses. Gowers says that the frequency 
of the disease in adult women is chiefly due to maternity. The following are 
occasional causes mentioned by various writers : anaemia, prolonged muscular 
effort, alcoholism, onanism (Gowers), ergotism, violent excitement (Erb), irri- 
tation of uric-acid calculi (Eustace Smith). 

From the nature of tetany it would seem probable that it might occa- 
sionally result from preputial irritation, but I have not been able to find the 
history of any case in which this cause was assigned, either in the literature 
of tetany or in monographs relating to a narrow, irritated, or inflamed pre- 
puce. Tetany does not result, or very rarely results, from burns or ordinary 
wounds ; but Weiss in 1883 reported 13 cases in which it occurred from 
excision of the thyroid, and, according to Wolfler, in 70 cases of this opera- 
tion tetany resulted 7 times. 

It is remarkable that this disease appears to occur as an epidemic — a fact 
not easy of explanation, unless upon the supposition that the rheumatismai 
cause due to atmospheric conditions, or the psychical or emotional cause 
giving rise to imitation, is operative at the time. Bouchut says that tetany 
occurred as an epidemic in Germany in 1717, in Belgium in 1846. and in 
Paris in 1855. In the Paris epidemic it occurred equally among children 
and adults, and was the occasion of interesting observations by Aran and 
Barthez. Another epidemic occurred in Paris in 1876 and in its. environs, 
especially at Gentilly, where in a school the teacher and thirty pupils were 
affected ; but some of the pupils afterward confessed that they had feigned 
the disease. In New York City, in the first quarter of 1889, I saw so many 
cases that it seemed to me that tetany might properly be regarded as an 
epidemic. 

Symptoms. — Ordinarily, tetany occurs without any marked premonitory 
symptoms, but in some instances it is preceded by pain in the head or spine, 
vomiting without any previous indigestion or gastric derangement, and a 
general feeling of indisposition. Usually, in those old enough to express 
their sensations, tetany begins with tingling, burning, or other unusual sen- 
sory manifestations in the limbs. The tonic contractions occur suddenly, 
sometimes in the upper and lower extremities simultaneously. Rarely, the 
contractions occur in the upper extremities alone or in the muscles of the 
trunk. At first a feeling of stiffness is experienced, and this is followed by 
tonic contractions, with the fixing of the affected part in a state of per- 
sistent flexion or extension. Usually, as regards the upper extremities, the 
contraction of the thenar and hypothenar muscles causes hollowness of the 
palms of the hands ; the first phalanges of the fingers are flexed, the second 
and third phalanges extended, and the thumb adducted and flexed so as to 
press against the index finger or lie underneath it. The fingers sometimes 
incline toward the ulnar side, and sometimes are pressed against each other. 
Usually the hand is slightly flexed, as is also the forearm. The muscles 
which move the arm usually escape, but exceptionally there is adduction of 
the arm on the shoulder. The hand may be extended instead of flexed, 
and all the joints of the fingers extended, or they may all be flexed and the 
fist closed. 



TETANY. 645 

The thighs may be adducted or flexed, the legs extended or flexed, the 
foot extended, forming a talipes equinus, and the toes flexed, as in the fol- 
lowing interesting case now in Charity Hospital, which has been alluded to 
above. Though the patient is an adult, her case is related here since it aids 
in throwing light on the nature of the disease : 

Case. — Mary F. . native of the United States, seamstress, married, and 

of apparently healthy parentage, states that her health was good previously to the 
present sickness. She says that she has never had venereal disease and never taken 
stimulants in excess, though in the habit of using whiskey at breakfast. She had 
been married four years, and three years ago had a stillborn child at the seventh 
month, but has had no other miscarriage and has had no confinement at term. Her 
catamenia, which formerly were scanty and at unusually long intervals, have dur- 
ing the last four months been normal in regard to time and quantity. She has been 
subject to afternoon headaches for years. She has had the average appetite, has 
partaken largely of rye bread at her meals, and her stools have been normal. 

In January, 1888, the patient, being employed as a seamstress in a shop at a 
distance from her residence, began to experience unusual fatigue, and on returning 
from her day's work she frequently 

noticed a painful burning sensation p IG -j^ 

in her feet, the pain extending up- 
ward along the calves of her legs. 
This pain in the feet and legs gradu- 
ally increased until March 12, 1888, 
at the time of the deep snow accom- 
panying the " blizzard." After walk- 
ing through the snow she sat all day 
at her work with wet feet, and at this 
time she began to experience a dull 
intermittent pain extending from both 
ankles to the knees, and accompanied 
by great lassitude, so that walking re- 
quired an effort. In July the pain 
became more constant, but at the time 
of her admission into Charity Hospi- 
tal (August 17th) it was not so con- 
stant or severe. Soon after her ad- 
mission the feet became strongly extended, forming a talipes equinus, and the toes 
of both feet were also strongly flexed. Sensation in the toes, but not in the feet, 
was almost completely lost. A few days subsequently the fingers on both sides 
were similarly flexed, but without pain or loss of sensation. In about six months 
the flexion of the finger ceased, and she can now use them nearly as well as before 
the attack. The toes also are not so strongly flexed as at first, and they have re- 
gained sensation. The bladder has never been affected, but the sphincter ani was 
paralyzed for a time in August, so that the feces escaped involuntarily in bed. The 
patient's memory was considerably impaired after the exposure at the time of the 
"blizzard," but is now (June, 1889) apparently nearly or quite normal. Otherwise 
no impairment of the mental faculties has been observed. 

The tetany in this case has been, as usual, bilateral and for the most part equal 
on the two sides, with a little more acuteness of sensation in the right than left 
limbs. The feet continue in the position of talipes equinus, with toes flexed, and 
the contracted muscles hard to the feel, almost like cartilage. No oedema has been 
observed, but perspiration occurs from the extremities during sleep. 

In mild cases or those of ordinary severity the contractions are limited to 
the muscles of the extremities, and are more marked and persistent in those 
that move the hands, feet, fingers, and toes than in other muscles ; but in 
severe cases the muscles of the trunk and head participate. Contraction of 
the abdominal muscles produces rigidity of the abdominal walls. Spasm of 
certain of the thoracic muscles occasionally occurs, causing dyspnoea and 
even lividity. In some of these cases of embarrassed respiration the dia- 
phragm is probably involved. Opisthotonos, retention of urine, anteflexion 




646 LOCAL DISEASES. 

of the neck from contraction of the sterno-mastoids, fixation of the jaws 
from spasm of the masseters, retraction of the angles of the mouth, stiffness 
of the tongue, and indistinct articulation are occasional symptoms in severe 
cases of tetany. 

The contractions render the affected muscles hard and unyielding, and 
the child cries from pain when attempts are made to straighten the limb. If 
the spasm be slight some voluntary movement of the affected muscles is pos- 
sible, but it is restrained and difficult. In severe cases, with the muscles 
tense and unyielding, voluntary motion is impossible. Except in the mildest 
forms of the disease pain is felt in the contracted muscles, such as all people 
experience when a spasm occurs in the calf of the leg, and the pain may pass 
upward along the limb. The pain may occur in paroxysms with distinct 
intermissions, or, without ceasing, it may vary in severity at different times, 
probably from some variation in the degree of spasm. Certain subjective 
symptoms, such as numbness and tingling, which sometimes occur in tetany, 
may continue during the intermission or remission. After some hours or 
days the rigidly-contracted muscles relax and the disease disappears, except 
perhaps that a degree of stiffness remains. But the respite is usually not- 
long. The spasms recur, and several successive recurrences and intermis- 
sions take place, running over months, before the disease is permanently 
cured. During the intervals in the contractions the affected nerves and 
muscles are in ordinary cases unduly excitable, so that sudden pressure or 
percussion causes some contraction. 

Trousseau was perhaps the first who noticed and called attention to 
the fact that compression of the artery and nerve supplying the contracted 
muscles in tetany causes or increases the contraction. Occasionally this 
result cannot be obtained. 

It is an interesting fact that in cases which I have observed the spasms 
do not cease in sleep, though the contraction of the muscles may not be as 
great as when the patient is awake. 

The electrical excitability of the nerve which supplies the contracted 
muscles is increased. Gowers states that he has obtained contractions in the 
muscles of the face by the voltaic current from a single cell. The increased 
excitability of the nerves is apparent if either the direct or induced current 
be used. According to Erb, when the circuit is closed the earliest contrac- 
tions occur at the point of application of the positive pole. Both opening 
and closing the circuit cause a more prolonged contraction of the muscles in 
tetany than in health. When the contractions are strong, oedema sometimes 
occurs, especially upon the dorsal surfaces of the hands. It was present in 
cases treated by Henoch, who attributes it to compression and consequent 
passive congestion of the veins, produced by contraction of the interossei 
muscles, the congestion giving rise to serous transudation. When the parox- 
ysms are severe, perspiration sometimes occurs, and an erythematous redness 
may appear over the affected muscles. Occasionally in acute attacks the 
temperature is moderately increased, but ordinarily it is normal. Tetany 
does not usually affect the functions of the internal organs, but in a case 
related by Kussmaul and another by Nonchen albuminuria was for a brief 
period present, and in one recorded instance the urine exhibited traces of 
sugar during the paroxysms. Occasionally in long-continued tetany the con- 
tracted muscles undergo a degree of atrophy which is attended by dimin- 
ished electrical irritability. Gowers states that " general muscular atrophy " 
has also been observed following tetany. 

The following may be regarded as typical cases in tetany in infancy 
as I have observed it in New York. The first case occurred in the New 
York Infant Asylum during my term of service, and the resident physician, 



TETANY. 647 

Dr. Virginia M. Davis, has kindly furnished me the history from her note- 
book : 

Case 1. — Gertrude A , born in the New York Infant Asylum, April 30, 

1888, was well except a mild attack of pertussis until March 9, 1889, when she 
had a prostrated appearance, and the thermometer indicated a temperature of 105°, 
and a little later 105.5°. During the following six hours she had five large, watery, 
and yellow stools. She was restless, her features sunken, extremities cool, her sur- 
face covered with a clammy perspiration, and her pluse feeble. Her diarrhoea was 
checked, and she slept during the following night. From March 9th to 14th she 
had slight fever (100.4°-100.6°) and her stools were normal, but during the week 
ending with the 14th she lost one pound in weight. The following are the subse- 
quent notes of the case : 

March 14th.— Is restless; temperature in the morning 100.4°, in the evening 
103° : has had no stool in the last twenty-four hours. To-day has had for the first 
time contraction of the flexor muscles of the hands, feet, fingers, and toes, so that 
in the evening all the fingers and toes are firmly flexed. The dorsal surface of the 
hands and feet, and the fingers and toes as far as the articulations of the first and 
second phalanges, are oedematous. The flexions can be overcome by the employ- 
ment of considerable force, but the attempt is painful. An erythematous eruption 
has appeared over the upper part of the chest and upon the back. 

March 15th. — Temperature 100.6° ; thumbs extended, voluntary movement of 
fingers returning ; toes still flexed ; oedema as before ; rash fading ; stools normal. 
March 16th. Temperature 99°-99.8°. The contractures have entirely disappeared 
during the day. Had four stools. 17th. Bowels constipated ; slight contractures 
of the fingers. 18th. Morning temperature 103°; evening, 101°. In the evening 
contractures of both extremities disappearing ; stools normal ; gums swollen. From 
this time the constipation was relieved by small doses of calomel, and the tetany 
ceased. Some elevation of temperature was a prominent symptom previous to 
and during the tetany, and on one day (May 17th) an attack of general clonic con- 
vulsions or eclampsia occurred. The tetany ceased on the 18th or 19th, but 
between the 20th and 30th, maculae and papules appeared on the surface, due per- 
haps partly to the medicines employed, which were chiefly the bromides and 
chloral. 

Case 2. — Edward Mel , aged fifteen months (practice of Dr. Vineberg, but 

examined by myself), has healthy parentage, and no other child in family has had 
any nervous ailment, except a single attack of eclampsia during measles in one of 
the children. Edward is nourished in part at the breast and in part from the 
table. He has four teeth, all having cut the gum since the age of twelve months. 
He has had diarrhoea much of the time since birth, and during the last two months 
has had free perspiration from the head. The mother states that during the first 
months of his life he occasionally held his breath, especially at night, but with this 
exception no symptoms resembling a convulsive attack were observed until recently, 
when, during an attack of' coughing, his face grew red, his eyes turned upward, 
and his respiration ceased for a moment. When he was at the age of twelve 
months the mother first noticed that the toes were flexed and the feet extended as 
in talipes equinus. Considerable force was required to overcome the tonic contrac- 
tion of the affected muscles, and when the pressure was relaxed the feet imme- 
diately assumed the former position of talipes. The thumbs were strongly flexed 
across the palms of the hands, the index and middle fingers forcibly extended and 
separated from each other, and the ring and little fingers were flexed against the 
palm. These abnormal flexions and extensions continued more than three months, 
with occasional intervals of two or three days, during which the action of the 
affected muscles was nearly normal. The child presents evidences of rachitis in 
the shape of its head and enlargement of the epiphyses of the extremities. 

The treatment employed by Dr. Vineberg consisted in change of diet and in 
the use of the following prescription : 

R. Zinci sulphat., gr. ^ ; 

Atropise sulphat., gr. T ^. — Misce. 

To be taken three times daily. 

With this treatment the spasms of the muscles entirely disappeared within a week, 
and two weeks later had not returned. 



648 LOCAL DISEASES. 

The following case, related by Trousseau, gives a clear and vivid idea of 
the symptoms of severe tetany as it occurs in the adult. A dissipated 
young man was found one morning lying in the street, " stiff as a poker " 
from the occurrence of tetany during the night. He was conscious and 
complained of great pain, but spoke indistinctly from the clenched state of 
his jaws. Muscles in his extremities were rigidly contracted, and being 
unable to walk, he had fallen down and could not rise. The rigidity of 
the muscles of the chest and abdomen, and probably of the diaphragm, 
rendered respiration difficult. His face was livid, and he had paroxysms 
of dyspnoea that threatened suffocation. The tetany finally abated, and he 
was able to walk and attend to light duties, but at intervals he had recur- 
rence of the spasms, and finally died of phthisis. 

Adults, unlike young children, give a clear description of their subjective 
symptoms. Frequently — probably in a majority of instances in the adult, 
as in the child — tetany is preceded by certain sensory symptoms, as formi- 
cation, a sensation of weight or dragging, of heat or cold, or even of pain. 
Soon afterward in using the limbs the patient observes some stiffness or that 
the movements are not so free and easy as previously. The spasms succeed, 
and, as in children, their duration and severity vary greatly in different 
patients. In the adult, as in the child, in mild tetany the contractions are 
limited to the muscles of the hands, feet, fingers, and toes, and the severe 
disease usually attacks first these muscles, and afterwards extends to the 
muscles of the head, face, neck, and trunk. Cases might be cited from the 
literature of tetany in which the contractions occurred in the muscles of the 
face, causing unsightly visage, the motor muscles of the eye, causing strabis- 
mus, the pharyngeal and laryngeal muscles, the muscles of the tongue and 
diaphragm, causing embarrassment of speech, respiration, and deglutition, 
sterno-cleido and other muscles of the neck, changing the position of the 
head, and in the various muscles of the trunk. In a case observed by 
Dr. Herard the recti muscles in the abdominal walls stood out like two tense 
cords. However severe the disease may be, a marked remission or distinct 
intermission soon occurs, the progress of tetany being characterized by 
intervals of complete relief. In not a few of the reported adult cases tetany 
has reappeared at varying intervals during a series of } T ears, being due to the 
recurrence of the causes which first produced it. 

Pathology. — Since tetany in itself is rarely fatal, only a few post-mortem 
examinations have been made, and in these no lesions have been discovered 
which appeared to sustain a causal relation to the disease. In the spinal cord 
minute hemorrhages, points of apparent myelitis, lymphoid cells, hyperemia 
of the spinal meninges and of the cords in their upper portions (Boucbut), 
and softening of the cord in the cervical region, have been observed in certain 
cases, but these lesions are believed to result from the excessive functional 
activity of the cord. The exaggerated excitation of the motor nerves is 
probably also attended by some change in their nutrition. Growers says that 
change in their nutrition consequent on their excited action is undoubtedly 
present. He states that a nutritive change in the motor nerve-fibres is 
usually consequent on, and secondary to, a similar change in the motor cells 
of the spinal cord, the axis-cylinders of the nerves being prolonged processes 
of these cells. Slight changes have been observed in these cells in those 
who have had tetany severely, and the fact that this disease is bilateral 
indicates that it has a central origin. Gowers adds that the sensory nerves 
are also probably implicated, from the fact that sensory symptoms often 
precede the spasm of tetany. As to the seat of the disease, nothing fur- 
ther is at present known ; but Gowers after a careful survey of the facts 
relating to the pathology of tetany, remarks : " On the whole, our present 



TETANY. 649 

knowledge of the pathology of the disease points to the nerve-cells of the 
spinal cord and medulla as the parts chiefly deranged, and the way in which 
the cells in rare cases seem to undergo subsequent atrophy suggests that the 
disturbance is a primary one of the cells themselves, and is not produced by 
the agency of any vaso-motor mechanism. It is difficult to conceive that 
symptoms of such definite and uniform character can be the result of any 
vascular spasm. The occasional wasting, with diminished irritability, is 
especially important as suggesting that the nutritional changes in the motor- 
cells and fibres, causing the increased excitability, may sometimes go on to 
structural degeneration." 

Diagnosis. — It may assist in the diagnosis to ascertain that the attack 
has immediately followed the occurrence of one of the recognized causes of 
tetany, as diarrhoea or other intestinal ailment or exposure to cold. We may 
diagnosticate tetany from tetanus from the fact that it is very rare under the 
age of one month, if indeed it ever occur in the newly-born, whereas tetanus 
almost never occurs in infancy after the first month or in childhood, nearly 
all cases occurring during the first three weeks after birth. It is also dis- 
tinguished from tetanus by the fact that it begins in the extremities, has 
periods of cessation or intermittence, and the masseters, which in tetanus 
early undergo the peculiar tonic contraction, are not affected or are affected 
only at a late stage and in the most severe cases. 

In organic disease of the brain the contractions do not, as a rule, intermit, 
and they are frequently limited to one side ; besides, other symptoms clearly 
referable to the brain are usually present. The bilateral and symmetrical 
nature of tetany, the occurrence of the contractions in corresponding groups 
of muscles on the two sides, distinguish the disease from those contractions 
which occur from lesions in the course of the nerves. 

Prognosis. — Tetany, whether intermittent, remittent, or occurring with 
little variation in the spasms, soon ceases in some cases and never returns. 
In other instances it does not cease entirely for months, though varying in 
severity at different times. Certain patients have attacks of it at intervals 
during a series of years, their health being good when not affected by it. 
Thus the case of a woman is related whose first attack was at the age of 
twenty-two years, and who had a recurrence of the disease every winter, and 
was still having it at the age of thirty-four years. This appears to have been 
one of those cases which have been attributed to a rheumatismal cause inci- 
dent to cold weather. Lussana relates a similar case in which tetany occurred 
each winter during ten successive years. In some instances years elapse 
between the attacks, as in a case related by Choostek. Maccall states that 
a woman had tetany five times when wet-nursing five successive children, and 
ivas well in the intervals. 

During infancy and childhood tetany, when uncomplicated, ends favor- 
ably, with possibly now and then a rare exception. In this respect it con- 
trasts with tetanus, which, whatever the age, is, with few exceptions, fatal. 
The few cases found in the literature of this disease in which death appar- 
ently resulted directly from tetany have been, so far as I have been able to 
ascertain, adults. Dr. Blondeau states that in Lourcine Hospital, Paris, a 
young woman whose health had been greatly impaired by syphilis and a mis- 
carriage had an obstinate diarrhoea. Tetany set in with great violence. The 
muscles of the face, neck, and chest were rigidly contracted. The face was 
livid, the eyes fixed, the pulse could not be counted, and the breathing was 
labored and stertorous. She was bled from the arm, and subsequently twelve 
leeches were ordered to be applied behind the ears, but during their appli- 
cation she died. The post-mortem examination, conducted with great care. 
revealed an apparently healthy state of all the organs except " trace of con- 



650 LOCAL DISEASES. 

gestion in the meninges, the veins of which contained a little more dark 
blood than usual." Gowers states that death may occur in consequence of 
pulmonary congestions and a low form of pneumonia which result from 
repeated attacks of tetany. Tetany following excision of the thyroid is more 
likely to be fatal than when it occurs from other causes. But, we repeat, so 
rarely is tetany fatal that most of those who have contributed to the litera- 
ture of this disease have never observed a fatal case. Muscular weakness 
for a time, and even more or less muscular atrophy, occasionally follow an 
attack of tetany. 

Treatment. — The cause or causes of the attack, so far as they can be 
ascertained, should obviously be promptly treated, and if possible removed. 
Especially should diarrhoea or any other abnormal state of the digestive sys- 
tem receive appropriate treatment, If the patient have been exposed to cold, 
and the cause be apparently of a rheumatismal nature, warm baths and 
diaphoretics, such as are employed in breaking up a cold, may be advantage- 
ously employed. 

In the treatment of the tetany of children the bromide of potassium is a 
most useful remedy. Four grains dissolved in cold water or any convenient 
vehicle may be given every third or fourth hour to a child of from one and 
a half to two years. It is a safe remedy, and it usually causes a diminution 
or cessation of the spasms. Cannabis indica, chloral, and hypodermic in- 
jections of morphia which have been employed in adult cases with apparent 
benefit should not be recommended for young children. It will be recollected 
that in the case treated by Dr. Vineberg, related in a preceding page, the 
infant at the age of fifteen months took one-quarter of a grain of sulphate 
of zinc and yl^ of a grain of sulphate of atropia three times daily, and with 
this treatment and a change of diet recovered within a week. Chloroform 
inhalation has been used, and during the narcosis produced by it active 
massage treatment of the affected limbs has been employed with apparent 
benefit. Growers states that faradism is contraindicated, and that the best 
results have been obtained from the voltaic current, either with both poles 
applied to the spine or with the negative pole to the spine and the positive 
over the affected muscles. But the treatment by electricity, by chloroform, 
and, we may add, by ice over the spine, as practised by Trousseau, is more 
applicable to adult cases than to children. 

A large proportion of children having tetany exhibit rachitic symptoms, 
and when such symptoms are present cod-liver oil and iron should be pre- 
scribed, and at the same time that the bromide of potassium and other reme- 
dies designed to relieve the tetany are employed. 



CHAPTER XI. 

CHOKEA. 

Chorea, St. Vitus's or St. Guy's dance, is a neurosis which is charac- 
terized by irregular and involuntary muscular movements, without loss of 
consciousness. The movements occur in the muscles of volition, and there 
is probably no one of them that may not be engaged, though some are more 
frequently affected than others. It is not known that any involuntary mus- 



CHOREA. 651 

cle is ever involved, though Sir William Jenner has expressed the opinion 
that occasionally the papillary muscles of the heart are, so that by their 
spasmodic contractions they produce insufficiency of the mitral valve. This, 
according to him, affords explanation of the fact that in certain instances a 
mitral regurgitant murmur is heard, which disappears about the time that 
the external movements cease. It is rare, however, that a mitral regurgitant 
murmur, heard during chorea, ceases when the latter terminates, and it is 
not improbable that in such cases there is, after all, a lesion of the valve, 
due to recent endocarditis, whether of a rheumatic or other origin ; for a 
valve may be so thickened by recent inflammation as to cause a murmur, and 
after a few weeks or months the infiltrating substance be so absorbed that 
the murmur is no longer audible. If we admit the fact that cardiac bruits 
occasionally appear and disappear with chorea, this explanation seems to me 
more plausible than that of Jenner. Hillier says in reference to this sub- 
ject : ,k My own experience leads me to doubt the existence of dynamic apex- 
murmurs in chorea ; that is to say, murmurs produced in hearts entirely free 
from organic change. If such murmurs ever occur, they are certainly rare. 
Organic murmurs of the heart, on the other hand, are common in chorea, 
and I am inclined to believe that organic disease of the heart often exists in 
chorea when there is no murmur." We shall see, by a case presently to be 
related, that this opinion is correct. Hillier also calls attention to the fact 
that choreic movements are irregular ; but a cardiac bruit occurring regu- 
larly and uniformly, if not due to organic disease, would require rhythmical 
contractions of the papillary muscles to produce it. We infer from this that 
the bruit does not have a choreic origin. 

In the class of children's diseases in the Bureau for the Relief of the Out- 
door Poor in New York City, 16,986 children were treated in the two years 
and three months ending with March 31, 1877. Of these cases 82, or 1 in 
every 207, had chorea. The patients were all under the age of fifteen years. 
Statistics published by observers in Europe show that the relative frequency 
of this disease is probably about the same in the large European cities as in 
New York. Thus, according to Hillier, among 122,621 out-patients treated 
at the Hospital for Sick Children in London, 406, or 1 in 322, had chorea, 
while of the in-patients, 174 in 5585, or 1 in every 32, were choreic. In the 
Parisian Hospital for Sick Children, of 84,968 admitted in twenty-one years, 
531 had chorea, or 1 in every 161. 

Age. — Chorea may occur at any period of life, but a large majority of the 
cases are in childhood. It is rare in infancy and it rarely begins after puber- 
ty. Under the age of five years the proportionate number diminishes as we 
approach the time of birth. The youngest in the statistics of Hillier was 
three months. In 1870, in the Bureau for the Out-door Poor a child was 
presented for treatment who, the mother said, had had chorea from birth, 
and in 1877, I treated a young woman with severe general chorea who, 
repeatedly questioned, uniformly said that she had had the disease, without 
any assignable cause, from the first week of her life, and her friends corrobo- 
rated the statement. The following table exhibits the relative frequency of 
chorea at different ages : 

6 years. 6 to 10 10 to 15 
and under, years. years. 
Children's Hospital, London, Hillier, none over 12 years 

admitted 81 237 104 

M. Bufz 10 61 118 

Bureau for Out-door Poor (prior to 1875) 2 26 16 

At and under 3 to 5 5 to 10 10 to 15 

3 years. years. years. years. 

Bureau for Out-door Poor (since January 1, 1875) 5 30 337 3 30 



652 LOCAL DISEASES. 

M. See collected the statistics of 531 cases occurring in the Children's 
Hospital, Paris, and from them concludes that the maximum frequency of 
chorea is between the sixth and tenth years. Only 28 of his cases were 
under six years, the remainder, 503, occurring between the sixth year and 
puberty. 

Causes. — The profession are nearly agreed in regard to certain causes of 
chorea, while there is a diversity of opinion in reference to others. It is 
admitted that in a large proportion of cases there is a neuropathic state 
which antedates and predisposes to chorea. This state is often manifested 
in the family history by a proneness to affections of the nervous system, and 
in the individual by a highly excitable state of the emotions, so that he 
evinces joy, grief, or anger from slight causes. 

All writers admit that there is often an inherited predisposition to chorea. 
In 27 of -48 cases, Radcliffe found that father, mother, brother, or sister had 
been or was the subject of one or other of the following disorders : paralysis, 
epilepsy, apoplexy, hysteria, or insanity. The children of parents who when 
young had chorea or who exhibit proneness to ailments of the nervous sys- 
tem are more liable to chorea than other children. Hence the fact, some- 
times observed, of different children in the same family becoming affected 
with chorea when they attain the age at which this disease ordinarily occurs. 
In one family in my practice three girls at different times were affected. 

Sex. — The emotions are strong in girls, since in them the nervous system 
predominates, while the muscular power is weaker than in boys. Hence a 
partial explanation of the fact which statistics fully establish, that the pro- 
portion of choreic boys to girls is about in the ratio of one to two and a frac- 
tion. I have remarked, in this city, the large proportion of cases in school- 
girls between the ages of six and twelve years, the severe discipline and 
confinement of the public schools no doubt increasing the strength of the 
emotions, and weakening the control of the will over the muscles. 

Proportion of Males to Females. 

27 to 73. Hughes's Digest of Cases in Guy's Hospital, 1846. 
138 to 393. M. See. 

50 to 94. Out-door Department, Bellevue. 
276 to 499. Children's Hospital, London, West (Lumleian Lectures). 
491 to 1059=1 to 2.15. 

The cases treated in the Out-door Department, Bellevue, since those 
contained in the above table occurred, give a larger percentage of females. 
Between April, 1878, and December, 1883, 288 choreic cases were treated 
in this department, and of these the proportion of boys to girls was 1 to 2.4 
(Chapin). 

Uterine Irritation. — The peculiar changes occurring in the female at 
puberty constitute an important cause. Hence another reason of the excess 
of female cases. Dysmenorrhea and pregnancy are causes of a large pro- 
portion of cases in the first years of puberty. In the male, on the other 
hand, the changes of puberty do not appear to increase the liability to the 
disease, directly or indirectly, and male cases after the age of twelve years 
are comparatively rare. Radcliffe x states that after the ninth year females 
are more liable to chorea than males, in the proportion of 5 to 2, while before 
the ninth year the two sexes are equally liable to it. Carefully prepared 
statistics, however, notwithstanding the high authority of Radcliffe, show a 
preponderance of girls under the age of nine years, though not so great as 
over that age. In the Out-door Department at Bellevue, of 35 patients under 
1 Reynolds' System of Medicine. 



CHOREA. 653 

the age of ten years, 22 were girls, while of 20 from the age of ten years to 
sixteen. 15 were girls. 

According to West, 1 in 775 children with chorea, under the age of ten 
years, treated in the London Children's Hospital, 64 per cent, were girls. 

Ansemia. — Among the most common predisposing causes of chorea is 
anaemia. It is present in so large a proportion of cases, exhibiting itself by 
pallor of the countenance and other characteristic signs, that medicines 
designed to improve the quality of the blood are among the most efficient 
remedies. The peculiar neuropathic state already alluded to, which needs 
only a slight additional cause for the development of chorea, is no doubt 
largely dependent on impoverishment of the blood, if it be not sometimes due 
entirely to it. Among the poor of a large city like New York or in hospital 
practice the proportion of anaemic cases of chorea is, for obvious reasons, 
much larger than would appear from the general statistics. 

Rheumatism. — Dr. CopelancL, M. Bouteille, and afterward M. Germain 
See in a more extended monograph, directed the attention of the profession 
to rheumatism as a cause of chorea. Subsequent observations have estab- 
lished the fact that rheumatism or the rheumatic diathesis is so frequently 
present that it obviously sustains an important relation to chorea, though in 
what manner is not fully ascertained. This relation between the two is more 
frequently observed in some countries than in others. In England and 
France so large a proportion of choreic patients present a history of rheu- 
matism, either in themselves or family, that certain physicians of these coun- 
tries believe that rheumatism is the most common cause of the disease. In 
Germany, on the other hand, according to Romberg, in the majority of cases 
no relation can be traced between chorea and rheumatism. Probably the 
largest number of choreic cases treated in one institution in this country is in 
the Bureau for the Relief of the Out-door Poor in this city ; and it has been 
our practice during the last few years to examine each patient for heart dis- 
ease and question the parents as regards rheumatism. Without referring to 
the exact statistics, I should say that at least one-third give the history of 
rheumatism in themselves or parents or had unequivocal signs of heart dis- 
ease. One of the physicians of the class found that 22 in 38 consecutive 
cases of chorea gave the history of rheumatism or of heart disease in them- 
selves or parents. 

Various theories have been promulgated in explanation of the relationship 
of the rheumatic and choreic diseases. It has been suggested that chorea is 
due to rheumatism of the brain or spinal cord. This is simply an hypothesis, 
the truth or falsity of which can only be ascertained by carefully-conducted 
necropsies ; but the theory appears improbable in view of all the facts. 
Another theory attributes chorea to the state of the blood which is present 
in those having rheumatism or the rheumatic diathesis, as well as in certain 
other conditions. This theory is enunciated by Dr. Ogle as follows : " Recog- 
nizing the frequent existence of these fibrinous deposits or granulations on 
the heart's valves in chorea, I should be much inclined to look upon these 
post-mortem appearances rather as results of some antecedent general con- 
dition of the blood common also to the choreic condition. It is very freely 
recognized that this affection is frequently in some way or other, connected 
with that condition of blood which obtains in what we call anaemia or that 
existing in rheumatic constitutions. In both of these states we know that 
the fibrin of the blood is much in excess (as also it is in pregnancy, another 
condition looked upon as obnoxious to chorea) ; and in these states we know 
that the fibrin with which the blood is surcharged is very prone to be readily 
precipitated, either owing to its superabundance or from other obscure and 

1 Lumleian Lectures. 



654 LOCAL DISEASES. 

acquired properties, .... upon the heart's walls or valves. May not this 
hyperinosis be the explanation of the coincidence alluded to?" 1 — namely, the 
occurrence of chorea in those affected with rheumatism. Others still hold 
that chorea is the result of the heart disease, and not directly of rheumatism, 
occurring when the heart is affected from other causes as well as when the 
lesion has a rheumatic origin. This theory is plausible, and probably to a 
certain extent correct. Heart lesions observed in children result from scarlet 
fever in a considerable proportion of cases, though it is true that the endo- 
carditis and pericarditis of scarlet fever are believed often to have a rheumatic 
origin, occurring in some instances from scarlatinous rheumatism, but in other 
cases from scarlatinous uraemia. Occasionally also the heart disease appears 
to have occurred independently of both rheumatism and scarlet fever. Thus 
in a fatal case of chorea with valvular disease related to the London Patho- 
logical Society, April 6, 1869, the child was always healthy up to the present 
illness (chorea), and there was no history of rheumatism in the family. The 
more observations accumulate the more important does heart disease in itself 
appear as a cause of chorea. In nearly all recorded cases of fatal chorea 
which were supposed to be due to rheumatism, and in which post-mortem 
examinations were made, endocardial and usually valvular disease has been 
found. We shall see that certain eccentric causes of irritation aid in pro- 
ducing chorea, and may not the valvular disease or the endocarditis which 
causes the valvular lesion operate in a similar manner as a cause ? We know 
that in the adult severe cardiac disease often profoundly affects the nervous 
system, perhaps in consequence of the irregular and embarrassed circulation, 
and certainly in the child a similar cause would be likely to produce a more 
decided effect. 

But there is an ingenious theory which attributes chorea to minute emboli 
detached from vegetations on the valves, and arrested by capillaries in the 
corpora striata or other portion of the cerebro-spinal axis. Since attention 
was directed to this matter, emboli have been found in one case in the 
medulla oblongata, although this portion of the spinal axis appeared healthy 
to the naked eye. Further observations are necessary in order to determine 
how much truth there is in this theory ; but it seems probable, for reasons to 
be stated, that if capillary embolism do cause chorea, it is only in a limited 
number of cases, and that therefore those British observers who regard it as 
the common cause have been led into error by the large proportion of choreic 
cases which in their climate are complicated by valvular lesions. 

That embolism is not a common cause, if indeed a cause at all, appears 
probable from the following facts : First. In many cases of chorea there are 
no vegetations or other appreciable lesions which could give rise to emboli. 
Secondly. Most patients recover, and some speedily, by treatment, which we 
would not expect if the cause were embolism. Thirdly. Embolism is not 
infrequent in the cerebral vessels of the adult without the occurrence of 
chorea. Indeed, the conditions which produce embolism are much more 
common in adults than in children, while the reverse is true as regards the 
liability to chorea. Fourthly. Dogs sometimes have chorea, but the injection 
of minutely divided fibrin or other substance into the veins of the dog is not 
followed by chorea as one of the phenomena. Fifthly. Were capillary emboli 
the cause, we would expect to find an occasional embolus in the larger vessels 
of the brain, so as to be appreciable to the naked eye ; but I find no examples 
of this in all the recorded autopsies which I have been able to consult. 
Moreover, it seems improbable that capillary embolism, when producing no 
lesion appreciable to the naked eye, would so arrest the circulation and dis- 
turb the function of the brain or spinal cord as to cause chorea, for the ill- 
1 British and Foreign Med.-Chir. Rev., January, 1868. 



CHOREA. 655 

effects of such an obstruction would be likely to be obviated by the numerous 
anastomoses. 

In 1877 the unusual opportunity occurred in my asylum practice of deter- 
mining whether there are any fixed anatomical characters in the cerebro-spinal 
axis in chorea ; in other words, whether chorea is a neurosis, as we have 
designated it in our definition, and the case is so interesting in other respects 
that I shall relate it entire : 

Case. — Charles , a foundling, born October 15, 1874, was received in the 

New York Foundling Asylum soon after his birth. When two weeks old he was 
removed to a family in the city to be wet-nursed. His health continued good till 
the age of three months, when he had bronchitis and keratitis, the former mild 
and lasting only a few days, but the latter continuing nearly two months, being- 
attended by moderate injection of the conjunctiva, with some purulent discharge, 
which caused adhesion of the eyelids during sleep. From this time he remained 
well, with the exception of a slight attack of dysentery, till the age of about nine 
and a half months, when he began to have febrile symptoms. In the morning 
hours he seemed in tolerable health, but at mid-day or a little later than mid-day 
of each day he was observed to have slight irregularity or embarrassment of 
respiration and lividity, with coolness of the extremities ; which state, supposed 
at the time to be the algid stage of a somewhat irregular intermittent fever, lasted 
from one to two or three hours, and was succeeded by fever, which continued during 
the remainder of the day : sometimes the fever abated in perspiration. 

On August 4, 1875, a few days after the commencement of these irregular febrile 
symptoms. Charles was brought to the dispensary of the institution for treatment, 
and Dr. Reid, who was on duty that day, carefully examined the case and pre- 
scribed the sulphate of quinia. This medicine, continued a few days, relieved the 
symptoms, but every four to six weeks, for more than a year, the febrile attacks 
returned, and were uniformly relieved by the same medicine. In other respects 
the patient had the usual health. 

On or about February 1, 1878, the nurse noticed that Charles had what she 
designated " spells of trembling," in which he seemed excited and feverish, and 
which were sometimes attended or followed by perspiration. In the course of 
another week the irregular muscular movements became more marked and constant, 
and they increased in severity till near the time of the admission of the patient into 
the asylum, about March 1st. The nurse had noticed in February slowness and 
some difficulty of micturition, and Dr. Reid examined him with a catheter for 
calculus, and also his prepuce for any source of irritation, but nothing abnormal 
was discovered, either in the condition of the bladder or the external organs. In 
the latter part of April the chorea had become so severe that irregular muscular 
action occurred in all the limbs and in the muscles of the eyes, producing such 
grimaces and contortions, with strabismus, that the woman with whom he was 
boarding became alarmed, and returned him to the asylum, stating that he had 
become crazy. 

On March 12th my attention was first called to this child, when I made the fol- 
lowing entry in my note-book : Family history unknown ; no history of rheumatism 
in patient's case ; he may or may not have had it ; heart sounds normal ; pulse 104 ; 
all the limbs and the muscles of the face, eyes, and eyelids involved in choreic 
movements, which continue constantly except during sleep. The patient cannot 
walk or stand without support : appetite good, apparently better than in health, 
for he eats every kind of food handed to him, and carries the food with his own 
hand to his mouth, although these movements are very irregular and jerking. 
Three drops of Fowler's solution ordered after each meal. 

March 17th. — Condition not much changed, but perhaps slight improvement ; 
in addition to other choreic movements the eyes twitch spasmodically ; pulse 84. 
temperature 98 J° ; bowels irregular ; no cough ; appetite good : increase medicine 
to five drops. 

30th. — The urine examined since the last record was found very pale and 
abundant ; its specific gravity low, 1004, without albumen. When an equal quan- 
tity of nitric acid was added to it, after twelve hours crystals of nitrate of urea 
occupied about one-half of the volume of the urine. The patient's sleep is quiet, 
but the choreic movements recommence as soon as he awakens, but in a milder 



6oQ LOCAL DISEASES. 

form ; is able to walk without support, but with unsteady gait. My term of 
service ended March 31st. On the following day laryngo-tracheitis was suddenly 
developed, ending fatally in forty-eight hours at the age of two years five and a 
half months. 

Autopsy, April 4th. — Slight oedema about the aperture of the glottis; general 
and intense redness of mucous membrane of larynx, trachea, and bronchial tubes •, 
as far as they can be traced, posterior portions of lungs greatly congested. The 
heart, lungs, brain with one eye attached to it by optic nerve, and the entire spinal 
cord were sent to Prof. Francis Delafield, for microscopic examination. They were, 
as soon as removed, placed in a solution of bichromate of potassium. The follow- 
ing is a brief statement of the examination which was made : 

Microscopic Appearances. By Prof. Francis Delafield. — Brain presented no 
change apparent to the naked eye except a considerable degree of congestion. It 
was hardened in bichromate of potassium and chromic acid. Minute examination 
of the convolutions of the brain, the large ganglia, the cerebellum, the pons Varolii, 
and the medulla oblongata showed nothing except a uniform filling of the vessels 
with blood, as if they were injected. There were no apoplexies, no changes in the 
walls of the vessels. 

Spinal cord appeared to be entirely normal. 

The Heart. — The auricles and ventricles were of normal size. The aortic valves 
were atheromatous and somewhat rigid ; the mitral valves were thickened and insuf- 
ficient ; the endocardium of the left ventricle was thickened. 

The Lungs. — The capillaries in the walls of the air-vesicles were dilated, and 
there was an increase of epithelial cells within the air-vesicles. 

In this case there seemed to .be no lesion associated with the chorea except the 
organic disease of the heart and the changes in the lungs secondary to this condition 
of the heart. 

The above microscopic examination was made with sufficient minuteness, and 
it is seen that no emboli were discovered and no lesion of the cerebro-spinal axis 
except congestion, which was attributable to the mode of death — namely, by 
obstructed respiration. Moreover, it will be recollected that there were no cardiac 
bruits, and apparently not sufficient roughness of the edge or surface of the valves 
to cause precipitation of fibrin, which would be necessary in order that emboli 
should form. 

Fright. — A not infrequent cause of chorea is sudden and profound emo- 
tion, especially fright. All statistics give fright as the cause of a certain 
proportion of cases, though there are usually other potential co-operating 
causes, as anaemia or valvular disease. Fright was stated as the cause of 
chorea in 31 of the 100 cases occurring in Gluy's Hospital reported by 
Hughes, or nearly 1 in 3. But the statistics of other observers do not give 
so large a proportion of cases originating in this way. Chorea may commence 
within a few hours after the fright or not till the lapse of several clays (eight 
or ten). If several weeks have passed since the fright, as in some reported 
cases, the chorea is probably due to other causes. In rare instances chorea is 
said to have been caused by sudden and excessive joy. 

Imitation. — Under unusual circumstances, especially in a state of great 
mental excitement, imitation has been known to cause a form of chorea. 
Hecker describes an epidemic of it occurring in the Middle Ages and spread- 
ing through villages. In modern times it is rare that chorea originates from 
this cause, nevertheless occasional examples have been recorded. 

But the disease which occurs from imitation differs from the ordinary form 
and has been termed chorea major, while the chorea which is the subject of 
this article is sometimes designated, in contradistinction, chorea minor. 

In chorea major the patient leaps, dances, or whirls like a top. It has its 
origin commonly in religious excitement, and spreads by imitation almost in 
the manner of an infectious disease. The epidemic of the Middle Ages was 
a chorea major. I have not been able to find any account of cases spreading 
by imitation in modern times which were not examples of the same form of 
chorea. Thus in the Edinburgh Journal of Medicine and Surgery, for July, 



CHOREA. 657 

1839. there is a clear description of chorea major occurring successively in 
five children in the same family. Dr. Dewar, the attending physician, states 
that one of the children whom he was called to see was sitting near the fire- 
place, when her head dropped on her chest and she appeared to doze for some 
minutes. In the mean time the respiration became a little accelerated, the 
face altered and flushed, the eyes wild. In less than one minute she bounded 
from one extremity of the apartment to the other, leaping over chairs, a chest, 
and then throwing herself upon the floor ; she attempted to stand upon her 
head, rolled upon the floor, and then, rising, ran with extreme swiftness in 
the room, till she finally fell again upon the floor, where she remained motion- 
less some minutes. Then, recovering, she noticed those who surrounded her, 
and asked of her sister a toy which she had allowed to fall. The whole 
paroxysm lasted twenty minutes. 

Obviously, the symptoms of chorea major differ materially from those of 
chorea minor, and it is a question whether it should have the same generic 
name. It is a curious and interesting disease in its psychical and pathologi- 
ical aspect, but it is so rare in modern times that a knowledge of it is of little 
practical importance. 

Intestinal Irritation. — In rare instances intestinal worms cause chorea, 
though in these cases there have usually been some co-operating causes. 

The following is an example related by Mr. Ogle : 1 " Ellen L , nine 

years old, had been under treatment about a month with chorea, rheuma- 
tism, and worms. She had not slept in four days, and there was constant 
spasmodic movement of the body and face. Her general condition was very 
unpromising. As she had passed portions of a tape-worm at intervals during 
the last three months, one drachm of the oleum filicis maris was administered in 
mucilage, which caused the expulsion of the entire worm. From that time she 
fully and rapidly recovered from the chorea, though a mitral murmur remained." 

Lesions of Brain and Spinal Cord. — Although we reject the theory that 
cerebral emboli are the common cause of chorea, and believe that in a large 
majority of cases there are no cerebro-spinal lesions, nevertheless experi- 
ments and also occasional cases establish the fact that if not true chorea, at 
least choreiform movements now and then result from a structural affection 
of the nervous centres. 

Experiments on certain of the lower animals demonstrate that irregular 
muscular movements may be produced by traumatic injury of certain por- 
tions of the cerebro-spinal axis, as the corpora quadrigemina, crura cerebri, 
pons Varolii, crura cerebelli, thalami optici, parts of the medulla oblongata, 
and the upper portion of the spinal cord. Pressure on the projecting part 
of the medulla oblongata of an acephalous monster also causes convulsive 
movements. At the meeting of the New York Academy of Medicine, April 
20, 1871, Professor Post related the case of a child who was struck over the 
occiput with a billet of wood, and chorea followed, due, in all probability, to 
the injury of the brain which resulted. 

If irregular muscular movements, choreic or choreiform, result from trau- 
matic injury of certain portions of the nervous centres, may they not also 
occasionally occur from lesions of the same parts produced by disease ? Sir 
Benjamin Brodie 2 relates the case of a choreic girl dying in St. George's 
Hospital, in whom, after a careful post-mortem examination, the only morbid 
appearance observed was a tumor the size of a hazlenut connected with the 
pineal gland. Dr. Broadbent 3 described another case before the London 
Pathological Society in which a tumor was found arising from the centre of 
the spinal cord ; and Chambers one in which tubercles were imbedded in the 

1 London Medico- Chir. Bev., Jan., 1868. 2 London Lancet, Dec. 19, 1S40. 

3 Transactions London Pathological Society, vol. xiii. p. 246. 

42 



658 LOCAL DISEASES. 

cord. Romberg quotes from Frerichs a case in which the medulla oblongata 
was pressed upon by an enlarged odontoid process ; and Dr. Aitkin ] one in 
which the specific gravity of the thalamus opticus and corpus striatum was 
greater on one side than on the other. Rilliet and Barthez relate other simi- 
lar cases, and they remark : " We may conclude from these different cases 
that there exist two species of chorea — the one essentially a simple neurosis, 
while the other depends on an alteration of the encephalo-rachidian system. 
In a word, it is of chorea as of convulsions, that it is sometimes idiopathic, 
sometimes symptomatic." Still, the cases in which it is symptomatic are so 
few that it is proper to consider chorea, as it ordinarily occurs, one of the 
neuroses until the microscope detects some anatomical cause in the cerebro- 
spinal system of which we are now ignorant. 

Anatomical Characters. — We have seen that chorea has no constant 
anatomical characters. Lesions which probably sustain a causal relation to 
the disordered muscular action are sometimes present, and others are some- 
times observed which are neither a cause nor a result, their presence being 
a coincidence. But there are two lesions which, though often absent, have 
been observed in so large a proportion of fatal cases that they are justly 
regarded as an occasional result when chorea is severe. Dr. Hughes of 
London collected records of the post-mortem appearances of 14 cases, with 
the following result as regards the cerebro-spinal axis : Brain, 14 cases ; 
healthy, 4 cases ; only congested, 3 cases ; softened in part or entirely, 6 
cases (some of these 6 also congested). In some of the 14 cases those occa- 
sional results of congestion — to wit, transudation of serum and extravasa- 
tion of blood in greater or less quantity — were also observed. Spinal cord : 
healthy, 3 cases ; congested, 2 cases (one slightly, in the other the engorged 
vessels were large and numerous) ; softening in medulla oblongata, 1 case ; 
softening opposite fourth and fifth vertebrae, 12 cases. In 1 there was soft, 
in another firm, adhesion of the spinal meninges, and in 1 it is stated that 
the rachidian fluid was opaque. Of 16 fatal cases of chorea occurring in 
St. George's Hospital, " congestion (more or less complete) of the nervous 
centres (brain or spinal cord, or both) was met with in 6 cases." Softening 
of certain parts of the brain was observed in 1 case, and of the spinal cord 
in another. 2 Other statistics of the anatomical character of fatal chorea 
correspond, in the main, with those of Hughes and Ogle. The lesions 
observed by them are probably not present in ordinary cases, occurring only 
when the choreic movements are so severe that the patient is deprived of 
needed repose and the important functions of the economy, as circulation and 
nutrition, are seriously disturbed. 

The post-mortem examination of other parts besides the cerebro-spinal 
axis furnishes a negative result, if we except such affections as have been 
ascertained to act as causes of chorea. What portion of the nervous centre 
is chiefly involved in chorea is uncertain. Some, as Sir Benjamin C. Brodie, 3 
consider chorea a disease of the nervous system generally, while others have 
attributed it to disease or disorder of a certain part, as the corpus striatum, 
cerebellum, etc. Finally, it is stated that in late experiments on choreic 
dogs the movements do not cease when the spinal cord is severed from the 
brain, nor also on division of the posterior roots of the spinal nerves. 4 In 
these cases, therefore, the part of the axis which is in fault would appear to 
be solely the spinal cord. 

1 Glasgoiv Medical Journal, vol. i. 

2 Ogle : Brit, and For. Medico-Chir. Rev., Jan., 1868. 

3 London Lancet, Dec. 19, 1840. 

4 Legros et Onimus : "Rech. sur les Movements choreiform^ du Chien," Acad, des 
Sci., 9 Mai, 1870, Lyons Med. Jour., June 5, 1870. 



CHOREA. 659 

Symptoms. — Chorea is partial or general. It is partial when it affects a 
few muscles or groups of muscles, as those of one arm, the face or neck, or 
of one eye. It is designated general when all the limbs and certain of the 
muscles of the face and trunk are involved. Statistics show that partial 
chorea occurs more frequently on the left than on the right side, and in gen- 
eral chorea the movements on the left side usually predominate. The com- 
mencement is in most cases gradual. Even when finally chorea becomes 
general, certain muscles only are affected in the commencement in ordinary 
cases. The child in whom this disease is about to begin is observed to be 
fretful and impatient from slight causes, and the irregular muscular action 
is sometimes misunderstood by the parents, who reprimand him for his sup- 
posed fidgety habit. In exceptional instances, especially when the cause is 
a sudden and profound emotion, the commencement is abrupt, and the disease 
is severe and general from the first. 

In a majority of cases the muscles which are primarily affected are those 
of the face, neck, fingers, or hand on the left side. Sydenham erred, unless 
the clinical history of chorea has changed during the last two centuries, when 
he stated as the common fact that a tottering gait is its first manifestation, 
but now and then such a case does occur. Whenever choreic movements 
appear other muscles besides those first affected are soon involved, so that in 
the course of a few weeks, sometimes of a few days, all the muscles that 
participate are engaged. 

A muscle affected by chorea alternately contracts and relaxes, but less 
forcibly and rapidly than in eclampsia, and the movement is partly controlled 
by volition. This produces an unsteady and tremulous action of the part, 
whether a limb, the neck, or the face, which at once arrests attention and 
indicates the nature of the disease. The result is similar, as regards the 
muscular action, whether the patient wills a movement or attempts to control 
those which chorea produces. 

If the case be of ordinary severity, the movements continue with but 
momentary intermissions, except during sleep, when they ordinarily cease. 
In grave cases patients are often deprived of the proper amount of sleep in 
consequence of the severity and persistence of the muscular action, and in 
exceptional instances, especially when the result is fatal, the movements con- 
tinue in sleep, but the sleep is not sound and is frequently interrupted. In 
profound sleep the muscles are always in repose. 

The older writers have left us graphic descriptions of those diseases which 
have striking external manifestations, though often with somewhat of exag- 
geration. Sydenham says of chorea : " The patient cannot keep it (his hand) 
a moment in the same place ; whether he lay it upon his breast or any other 
part of his body, do what he may, it will be jerked elsewhere convulsively. 
If an}^ vessel filled with drink be put into his hand, before it reaches his 
mouth he will exhibit a thousand gesticulations, like a mountebank. He 
holds the cup out straight, as if to move it to his mouth, but has his hand 
carried elsewhere by sudden jerks. Then, perhaps, he contrives to bring it 
to his mouth, and if so, he will drink the liquid off at a gulp, just as if he 
were trying to amuse the spectators by his antics." 

In severe general chorea a similar description is applicable to the move- 
ments of the legs and features. Grimaces and distortions of the features 
occur, while the gait is halting and unsteady, or it is impossible to walk, and 
the patient lies or sits. The speech is slow, thick, and indistinct in conse- 
quence of the muscles of the tongue and larynx becoming engaged, and even 
mastication and deglutition are rendered difficult. The imperfect speech in 
chorea is attributed partly, however, to the mental state in severe protracted 
cases. Chorea, except when mild, is accompanied by other symptoms refer- 



660 LOCAL DISEASES. 

able to the nervous system. More or less impairment of the mental faculties 
occurs in chronic cases when severe, exhibiting itself in dulness or apathy. 
The countenance sometimes presents in aggravated cases almost the appear- 
ance of idiocy. The muscles, instead of becoming hypertrophied and more 
powerful by their frequent contraction, grow softer, more flabby, and weaker. 
Indeed, a partial paralysis sometimes results, so that a degree of numbness is 
experienced in the affected part and the limb when raised cannot be sustained. 
Pain is not a symptom of chorea, but fugitive rheumatic or neuralgic pains 
are sometimes experienced. Derangement of the digestive function, exhibited 
by a poor or capricious appetite, constipation, etc., are common. 

In rare instances chorea affects the respiratory muscles so as to produce a 
peculiar involuntary barking or squeaking voice by the forcible expulsion of 
air over the tense vocal cords. In a case treated by Dr. L. C. Gray in the 
N. Y. Polyclinic the patient, a boy of fifteen years, had been choreic since 
his seventh year, and chorea in its usual form had continued one year when 
the barking sound commenced, and this has continued until the present time. 
Dr. French of Brooklyn also treated a similar case, having the following his- 
tory : A boy of nine years had choreic twitchings of the facial muscles at 
the age of five years. After continuing several months, they ceased during 
an entire winter, after which the peculiar sound of the voice, resembling the 
squeak of a young turkey, commenced. It occurred at the beginning, middle, 
or end of respiration. It alternated with choreic movements of other parts 
of the system, so that when they ceased it returned. By the laryngoscope 
the irregular action of the vocal cords was observed, but the expiratory mus- 
cles of the chest were also involved, so as to produce the peculiar sound by 
the forcible expulsion of air. In Dr. French's case these vocal sounds ceased, 
except at rare intervals, after three months of medicinal treatment. 1 

The urine of choreic patients has been examined by Drs. Walsh, Ford, 
Bence Jones, Handfield Jones, Badcliffe, and others, and its elements have 
been found in most cases to vary from their normal quantity. Dr. Handfield 
Jones 2 read a paper before the Clinical Society of London in 1871 on two 
cases of chorea in which he had made careful chemical analysis of the urine, 
with the following result : During the height of the disease the amount of 
the urine was much in excess of what it was when the disease had ceased ; 
the urea excreted during the choreic period was in excess, as was also the 
phosphoric acid excreted when the choreic symptoms were at their maximum, 
but the quantity of this acid was less than the average during convales- 
cence ; a moderate amount of uric acid during the disease was also observed, 
but none upon recovery. 

Prognosis ; Course. — Chorea, though obstinate and often incurable in 
adults, usually terminates favorably in children in two to four months. 
Bouchut considers its ordinary duration at from thirty to fifty days, which is 
certainly shorter than the average duration in this country, except when the 
disease is materially abridged by treatment. The same author states that it 
may continue only a few days, as he has observed in cases which occurred 
during convalescence from scarlet fever. But tremulousness of the muscles, 
occurring in the state of weakness following a grave disease and abating as 
the general health is restored, I should not consider as properly choreic, any 
more than that occurring from over-fatigue. As the choreic movements 
gradually increase in the initial period till a certain maximum is reached, so 
their decline is gradual. Temporary variations also occur throughout the 
disease as regards the extent of the movements, which are aggravated by 
mental excitement, bodily fatigue, certain functional derangements, especially 
of digestion, and sometimes from causes which are not apparent. 
1 N. Y. Med. Becord, Dec. 15, 1883 : Dr. Chapin. 2 London Lancet, July, 1871. 



CHOREA. 661 

Though, as a rule, chorea in children ordinarily terminates favorably 
under different and even injurious modes of treatment there are exceptional 
cases. Romberg relates the history of a patient who died at the age of 
seventy-six years, having had chorea since the age of six years. In chorea 
limited to a few muscles or a group of muscles the prognosis is more doubt- 
ful than when it affects a large number, since in the former case the cause is 
more likely to be some lesion of the cerebro-spinal axis. Thus, chorea 
involving only certain muscles of the neck or of the eyes is sometimes due 
to this cause, and is then very obstinate. 

Again, observations demonstrate that chorea, when at first, in all prob- 
ability, strictly a neurosis, but of a protracted and grave character, may give 
rise to a central organic disease. This is the course of most of the fatal 
cases, congestion, softening, or other lesion occurring over a greater or less 
extent of the nervous centres. Radcliffe has known cerebral meningitis to 
supervene in two instances. With the occurrence of a lesion of the cerebro- 
spinal axis new symptoms arise, such as headache, convulsions, delirium, and 
paralysis, and the choreic movements cease or continue according to the 
nature of the lesion. 

Chorea, like certain other diseases either of a nervous character or having 
a nervous element, is more or less modified by intercurrent inflammatory and 
febrile affections. The oft-quoted expression from Hippocrates, febris acce- 
dens solvit sjKismos, observations show to be founded on fact, the most frequent 
example of which occurs in pertussis. In chorea the movements, as a rule, 
are either rendered milder or they cease as long as the febrile excitement 
continues ; but there are exceptions, and the subsequent course of the disease 
is not modified. 

Diagnosis. — This is not difficult in ordinary cases. The irregular move- 
ments with consciousness preserved enable us to make a diagnosis at sight. 
In its commencement and when it continues in an unusually mild form 
chorea may be overlooked by the physician, as it often is by the parents, 
the movements being attributed to a fidgety habit ; but medical advice is 
seldom sought till the movements are so pronounced that it is impossible to 
err, except through gross ignorance or carelessness. 

It is important to determine when chorea occurs in an organic disease, 
and also whether there is a local cause of the chorea. A careful and intel- 
ligent study of the symptoms and history of the case is requisite in order to 
obtain a correct diagnosis in these particulars. 

Treatment. — Regimenal. — As chorea in a large proportion of cases occurs 
in a state of anaemia, and the vital forces are ordinarily more or less reduced, 
obviously the regimen should be such as invigorates the system. Fresh air 
and out-door exercise, active or passive according to circumstances, with the 
avoidance of undue excitement, are requisite, and the diet should be nutri- 
tious, but plain and unirritating. The various functions should be preserved 
so far as possible in their normal state. In exceptional instances, when the 
choreic movements are violent, the patient should lie in bed, and some writers 
have recommended the use of splints to restrain muscular action in such 
cases. I have found chloralamid an effectual remedy in these severe cases, 
allaying the muscular contractions and producing quiet sleep. It may be 
given in the following formula : 

R. Chloralamid, £j ; 

Spts. frumenti, 5j ; 

Syr. rubi idsei, gij. — Misce. 

Give one teaspoonful to a child of five years every two hours until the desired 
effect is produced. 



662 LOCAL DISEASES. 

Medicinal. — Sometimes among the co-operating causes is one of a local 
nature which is susceptible of removal, as a carious and painful tooth, intes- 
tinal worms, etc., and measures calculated to effect this are obviously required. 
Allusion has already been made to a case in which the employment of the 
oleoresina filicis and the expulsion of a tape-worm effected a speedy cure. 

The remedy which has been most employed in chorea, and which in 
consequence of the anaemia is plainly indicated in a large proportion of 
cases, is iron. It does not interfere with the employment of other remedies 
which have a more specific effect. Nearly all the ferruginous preparations 
have been prescribed in different cases with benefit. Radcliffe gives the 
preference to the iodide of iron, believing that iodide as well as iron exerts 
a curative influence. I have prescribed the ammonio-citrate, since it is easy 
of administration in simple syrup and is well tolerated ; but I now prefer 
liquor ferri peptonati or the pepto-mangan, recently introduced from Germany. 
It should be given in doses of one to three teaspoonfuls three times daily. 

But iron must not be regarded as the main remedy, but rather as an 
adjuvant. Observations during the last few years in both continents have 
more and more established the claims of arsenic to be regarded as the most 
efficacious of all medicinal agents in the treatment of ordinary chorea. 
Properly administered, it abridges the duration of this disease more certainly 
than any other agent, and within a few days begins to modify the choreic 
movements in the severest cases. It is conveniently given in the form of 
Fowler's solution. It is better tolerated by children than by adults, and 
should be administered to them in a larger proportionate dose. A child of 
eight years can take five drops, diluted in water, three times daily after 
eating, and the dose may be increased, if needed, to eight, ten, twelve, or 
even fifteen drops. I seldom observe any gastric irritability or other un- 
pleasant effect from its use when it is administered largely diluted and after 
the meals, but if such occur, it should, of course, be suspended for a time. 

While not hesitating to recommend iron and arsenic as superior to all 
other medicines in the treatment of chorea, it is not proper to ignore the 
opinions of other members of our profession who have had ample experience 
and recommend other agents instead. 

Trousseau gave the preference to strychnine, increasing the doses in some 
cases until it began to produce its poisonous effects. 

Professor Hammond 1 says: " My main reliance is on strychnia, which, I 
think, should be given in gradually increasing doses, somewhat after the 

manner recommended by Trousseau This plan of treatment certainly 

shortens the duration of the disease very materially, and causes great improve- 
ment in the general health of the patient. Sometimes the effect is so well 
marked and is so immediate that it is not necessary to increase the doses to 
the extent of causing muscular cramps, but generally the full therapeutical 
effect of the drug is not obtained till the calf of the leg or the nucha has 
slight tonic spasm. I have never seen the slightest ill-consequence follow 
this mode of treatment, and the doses are increased so gradually that with 
careful watching danger need not be apprehended." Dr. Hammond has 
treated thirty-two children with this agent without a single failure. 

But as chorea terminates favorably with smaller and safe doses, even 
if the time required be longer, it does not seem proper to recommend its 
employment to the extent of producing physiological effects for general 
practice. Bouchut, speaking upon this point, says : " But with these pre- 
cautions strychnia is extremely dangerous, for I have seen at the Hopital 
des Enfants Malades a young girl of thirteen years die in tetanus'' produced 
by an increased dose of this drug (article on Chorea). Dr. West, in his 
1 Diseases of the Nervous System, page 617. 



CHOREA. 663 

Lumleian Lectures, also says : " I have seen one instance in which its 
employment, while it failed to benefit a somewhat severe case of chorea, 
was followed by two attacks of violent tetanic convulsions, which nearly 
proved fatal ;" and he adds : ki The twitching of the limbs of itself prevents 
our becoming aware of the dose being excessive." Therefore, Dr. West does 
not favor the employment of this agent. Still, any agent may be given in 
an overdose, and it is not difficult to prescribe strychnia in a dose which may 
be efficient, and yet safe for children, at the age at which chorea ordinarily 
occurs. 

I have employed bromide of potassium in a few cases, but with so little 
benefit that I am not inclined to continue its use for this disease. Others 
have not been more successful. However efficacious the bromide may be in 
epilepsy, it does not appear to be a remedy for chorea. 

Cimicifuga. first employed by Jesse Young of this country, is highly 
esteemed by Philadelphia physicians in the treatment of chorea. I have 
employed the fluid extract in doses of half a drachm, increased to one drachm, 
for a child from six to ten years of age, and, though it benefits some cases, it 
has no appreciable effect either in moderating the movements or abridging the 
duration of others. 

Ether, asafoetida, valerian, musk, the oxide and sulphate of zinc, turpen- 
tine, tartar emetic, opium, and numerous other remedies have been recom- 
mended, and some of them have seemed useful in certain cases. In this city 
sulphate of zinc has been frequently employed as a remedy for chorea, and 
in gradually increasing doses till more than twenty grains were administered 
three times daily ; but it has not appeared, so far as I have been able to 
ascertain, to exert any marked influence either on the severity or duration of 
the choreic movements. Justice, however, requires us to state that Dr. West, 
who has written recently on the nervous diseases of children, thinks that it 
has been beneficial in certain cases in which he has employed it, and he 
regards it on the whole as the best remedy. 

Radcliffe, who has had ample experience in the treatment of nervous 
affections, writes : " In an ordinary case of chorea the plan of treatment 
which I have now adopted as a rule for some time is to give cod-liver oil in 
conjunction with hypophosphite of soda, making the draught containing the 
latter salt the vehicle for the administration of the cod-liver oil." Sometimes 
camphor or the sesquicarbonate of ammonia is added. Of more than thirty 
cases treated in this way, the average duration was under three weeks. Rad- 
cliffe began to prescribe these remedies on theoretical grounds, believing that 
phosphorus and cod-liver oil were required to restore " nerve-tone," and the 
result of this treatment has certainly been such as to commend it to the pro- 
fession. To children he gives from five to eight grains of the hypophosphite 
of sodium three times daily. 

In those severe cases in which choreic movements prevent the proper 
amount of sleep, a moderate dose of hydrate of chloral, or, better, as stated 
above, chloralamid may occasionally be advantageously administered. 

Electricity has been many times employed in the treatment of chorea, 
and though some, chiefly electricians, believe that it has a curative effect, 
others, and the majority, fail to see any material benefit from its use. 

Cold general baths, the shower-bath, frictions along the spine, etc.. have 
been employed ; but the local treatment which has so far been most success- 
ful, and which promises to supersede all other local measures, consists in the 
application of ether spray over the spine. About two ounces of ether are 
employed at each sitting, the spray being applied from an atomizer up and 
down the whole length of the spine if the chorea be general. The opera- 
tion, which occupies from ten to fifteen minutes, should be repeated daily or 



664 LOCAL DISEASES. 

every second day. A considerable number of cases have been reported in 
which the spray has apparently had a good effect in controlling the disease. 
But I repeat my belief, from the large number of cases seen in the Bureau 
for the Relief of the Out-door Poor, that the arsenical and ferruginous treat- 
ment gives more satisfaction than any or all other measures. 



CHAPTER XII. 

PARALYSIS. 

Paralysis in young children, especially infants, is in most instances due 
to causes which seldom produce it in adults. The principal cause of it in 
the adult — namely, cerebral apoplexy — is indeed rare in children. Paralysis 
in children has the following recognized causes : 1st. A change in the blood, 
not fully understood, induced by certain grave diseases, as diphtheria, typhoid 
fever, measles, scarlet fever, etc. 2d. Reflex influence. The function of 
some part of the system is in some way disturbed, and paralysis occurs in 
certain muscles, perhaps at a distance from the cause, and it disappears when 
that cause is removed, unless it have continued too long. The only rational 
explanation is found in the fact of a continuous connection between the local 
cause and the paralyzed muscles through the afferent and efferent nerves and 
the nervous centres. 3d. Compression or injury of a nerve-trunk. These 
cases are rare. Pressing of the portio dura by the blades of forceps during 
birth, described in the next chapter, is an example. 4th. An anatomical 
alteration in the muscular fibres, the nerves and nervous centres remaining 
unaffected. This has been designated myogenic paralysis. This form of 
paralysis is probably often of a rheumatic nature. Paralysis of the face or 
other portions of the surface, which sometimes occurs in children and adults 
from prolonged exposure to cold winds, is of this nature. 5th. Some anatom- 
ical change in the nervous centres, as congestion, hemorrhage, inflammation, 
emboli, compression and laceration of brain, whether by tumors, inflamma- 
tory products, or other causes, etc. If there be hemiplegia, the presumption 
is that the disease causing it is cerebral ; if paraplegia, that it is spinal. 

Paralysis occurring as a symptom or sequel of some obvious local or gen- 
eral disease, as diphtheria, lesion of the nervous centres, etc., and which may 
occur at any stage, need not detain us. It is described in connection with 
the primary diseases on which it depends. 



CHAPTER XIII. 

POLIOMYELITIS ACUTA ANTERIOR. 

This form of paralysis occurs, with few exceptions, between the ages of 
six months and seven years. 

Symptoms. — The previous health of the patient is usually good. The 
paralysis does not always commence in the same manner. In a few instances 
it begins suddenly in the day-time when the child is apparently in perfect 
health. In others it begins abruptly, after sound sleep. The child goes to 



POLIOMYELITIS ACUTA ANTERIOR. 665 

bed well, sleeps through the night, and awakens in the morning paralyzed. 
I have known it to occur in one instance after sleep in the middle of the 
day. In these cases there has sometimes been an exposure before the sleep 
to wind or rain or from sitting on a cold stone. But in the majority of cases 
the paralysis is preceded and accompanied by a very decided elevation of 
temperature, which comes on suddenly without appreciable cause, and after 
a few days the power of motion is found to be lost in one or more of the 
limbs. Xo symptom occurs during the fever indicative of disease of the 
brain ; consciousness is retained, and the headache or apparent liability to 
convulsions is no greater than in other pathological states accompanied by an 
equal amount of fever. The paralysis is at its maximum in the commence- 
ment. Occurring as by a stroke, the full extent of the paralytic state is 
exhibited at once, and so far as there is any subsequent change it is an im- 
provement as regards the number of muscles affected and the degree of the 
paralysis. Most frequently the muscles of one or both lower extremities are 
affected. Occasionally one of the upper extremities is also paralyzed in 
addition to the lower, but paralysis of an upper extremity is less in degree, 
and disappears sooner, than of the lower. The bladder and lower bowel 
remain unaffected, since only the muscles of volition are involved. Sensation 
is unimpaired in the affected limbs, and in the commencement there is even 
in some cases a state of hyperesthesia (West). The fever which precedes 
and accompanies the paralysis in certain cases gradually abates, and in a few 
days nothing abnormal remains except the loss of power in the affected mus- 
cles. These muscles are flaccid and relaxed, so that the limb falls by its 
weight when unsupported, and they are usually free from pain. The number 
of muscles paralyzed varies greatly in different cases. Only one muscle or 
a single group of muscles may be affected, or, on the other hand, both the 
extensor and flexor muscles of two or more limbs may be paralyzed. In the 
opinion of Mr. Adams, the following table exhibits the groups of muscles 
and single muscles most frequently involved, and in the order stated : 

Groups. 

1. Extensors of toes and flexors of the foot. 

2. Extensors and supinators of the hand. 

3. Extensors of leg, and with them usually the first group. 

Single Muscles. 

1. Extensor longus digitorum of toes. 

2. Tibialis anticus. 

3. Deltoid. 

4. Sterno-mastoid. 

The following is an example of infantile paralysis as it not infrequently 

occurs when the result is favorable : A. K , German, female, aged three 

years and four months, fleshy ; had been in the habit of sitting on the ground 
near the house and on the door-sill. On July 2, 1871, she had a sound sleep 
in the afternoon, having been entirely well previously, and awoke trembling 
and with a high fever at 3J p. M. At 8 P. M., the febrile excitement con- 
tinuing, general clonic convulsions occurred, lasting about ten minutes. At 
this time I was called to see her, and found her face flushed, surface hot, and 
pulse about 130. Consciousness returned after the convulsion. Her intelli- 
gence was good, tongue moist and slightly furred, bowels rather constipated, 
and the urine freely passed. The fever continued two days, when it grad- 
ually and entirely abated, but before it ceased paralysis of the left lower 
extremity was observed. No weight at first could be sustained upon this 
limb, and it hung powerless when we endeavored to make her walk. The 



6QQ LOCAL DISEASES. 

attempt roused her to cry, as if in pain, and pressing upon the thigh or 
moving it had the same effect. The thigh of this limb appeared slightly 
swollen on inspection, but measurement did not indicate any notable enlarge- 
ment. The difference in circumference was not more than one-eighth to one- 
fourth of an inch. There was no appreciable increase of heat in the thigh 
over the general temperature of the body. Sensibility remained in every 
part of the limb, and the loss of power was not complete, for on the first 
day, as soon as the paralysis was observed, slight and imperfect movements 
could be produced by pinching the limb. In three weeks the use of the 
limb was fully restored by mildly stimulating liniments and simple medicines 
to regulate the bowels. The tenderness which was observed in this case is 
only occasionally present, and has been attributed to hyperesthesia. 

Prognosis ; Progress. — The paralysis in nearly all cases soon begins to 
abate. The power of motion returns little by little, and whatever improve- 
ment occurs is permanent. There is no retrogression in the convalescence. 
The sooner improvement commences the more favorable is the prognosis. In 
the most favorable cases there is complete restoration in from three to four 
weeks. In other patients, while certain of the muscles regain the power of 
motion, other muscles, oftener those of the lower extremity than of the 
upper, do not recover their function, and, unless proper remedial measures be 
employed, and even with them in certain instances, atrophy soon commences. 
The temperature of the paralyzed limb falls three, five, or even eight degrees, 
and the amount of blood which circulates in it is diminished, so that the 
pulse of the limb is feebler and its vessels smaller than in health. With the 
atrophy the contractility of the muscular fibres by the electric current dimin- 
ishes, and in unfavorable cases after a time powerful induced and even pri- 
mary currents have no appreciable effect. The nutrition of a paralyzed 
limb is always imperfect, and if the paralysis occur in a child its growth 
is retarded. Therefore, in cases of contracted or permanent infantile paralysis 
of one limb a disproportion occurs both in diameter and length between it 
and that on the opposite side. If the paralysis continue, the ligaments of 
the paralyzed limb become relaxed and lengthened. West mentions a case 
of paralysis of the deltoid in which the humero-scapular ligaments were so 
extended that the humerus dropped from the glenoid cavity, so as to increase 
the length of the limb three-fourths of an inch. In the paralysis of certain 
muscles of the lower extremity and continuance of the contractile power 
in others we have the conditions which give rise to club-feet, and accord- 
ingly this deformity is the common result of the paralysis when it is not 
cured. 

Etiology. — As this form of paralysis is not fatal, opportunity for post- 
mortem examination in a recent case seldom occurs. Hence the difficulty in 
determining the exact anatomical change in the nervous system which pro- 
duces the paralysis. Medical literature contains records of a considerable 
number of cases in which autopsies have been made, but death occurred so 
long after the commencement of the paralysis, usually months or years, that 
it is difficult to determine whether lesions which have been observed were a 
cause or consequence. In a majority of these autopsies a spinal lesion of 
some sort was detected, but in some instances none could be discovered. 

Mr. Adams in his treatise on club-foot relates a case in which the spinal 
cord, carefully examined, probably only with the naked eye, seemed normal. 
Robin examined the spinal cord microscopically in one case, but discovered 
nothing abnormal, and Elischer made autopsies in two cases of this paralysis 
in which death had occurred from variola, but with a negative result as 
regards the nervous system. 1 The examinations by Robin and Elischer r 
1 Jahrbuch fur Kinderh., 1873. 



POLIOMYELITIS ACUTA ANTERIOR 667 

since they were microscopic, have been justly regarded as important, and 
they have been related by writers in order to sustain the theory that infantile 
paralysis is peripheral and not centric. 

Very little was effected prior to 1863 in determining the cause or causes 
of this paralysis by post-mortem examinations, because the microscope was 
so little used, and because in most of the cases reported the clinical history 
or microscopic lesions were such as to show or to render it highly probable 
that the paralysis was not of the kind which we have been describing. 
Thus, Beraud reported a case in which tubercles were found in the spinal 
cord ; Hammond, a case in which a clot was found in the spinal cord ; and 
Jaccoud, one of spinal arachnitis with thickening of the meninges. Since 
1863. 17 autopsies have been recorded in which the spinal cord was carefully 
examined, and upon these we must chiefly rely for our data by which to 
determine what are the anatomical changes in the nervous system which 
probably cause this paralysis. The reader will find these cases tabulated in 
a lecture by B. Gr. Seguin, M. D., 1 and the most important of them narrated 
in a paper on infantile paralysis, showing great research, published by Dr. 
Mary Putnam Jacobi. 2 It is true that all but 3 of these post-mortem 
examinations were made many years after the occurrence of the paralysis; 
but in the 3 cases which were reported by Roger and Damaschino, only two, 
six, and thirteen months had elapsed. The following were the chief lesions 
observed in these cases as regards the spinal cord : 

Cases. 

1. Atrophy of motor-cells in anterior cornua 10 

2. Nerve-cells, normal 2 

3. Atrophy (variously recorded) of anterior columns, or cornua, or part 

of cord, or roots of anterior nerves 8 

4. Sclerosis 9 

5. Myelitis, recorded as diffused, central, or slight 7 

6. Central softening (the three most recent cases) 3 

7. Small clot in cord (Hammond's case) 1 

8. Sciatic neuritis 1 

The most common lesions in these cases were those of inflammation of 
the anterior cornua of the spinal cord, or such as are known to result from 
this inflammation — to wit, atrophy of the nervous substance and sclerosis. 

With the data furnished by these post-mortem examinations and the clin- 
ical histories of cases we are better prepared to consider the theories regard- 
ing the etiology of this malady. The views of MM. Roger and Damaschino 
are entitled to much consideration, since the autopsies which they made were 
in cases of shorter duration, and therefore nearer the date of the commence- 
ment of the paralysis, than those which have been reported by other observ- 
ers. Roger and Damaschino 3 published a series of papers on this malady, 
which they conclude with the following propositions : "1. The alteration 
peculiar to infantile paralysis is a lesion of the spinal marrow, which causes 
the atrophy of muscles and nerves. 2. The seat of this lesion is the anterior 
part of the gray substance of the medulla, where softened portions of spinal 
substance are seen. 3. This softening is of an inflammatory nature — in fact, 
a simple myelitis. 4. Infantile paralysis should therefore be called spinal 
paralysis of children, and be classed among the affections of the spinal 
marrow, as depending on myelitis." 

The views of Roger and Damaschino, expressed above, seem to harmonize 
more closely with, and to afford a more satisfactory explanation of, the symp- 
toms, history, and lesions thus far observed in ordinary or typical cases than 

1 N. Y. Medical Record, January 15, 1874. 2 N. Y. Obst. Jour., for May, 1S74. 
3 Gaz. tried, de Paris, 1874. 



66S LOCAL DISEASES 

does any other theory. Many neuropathists regard suddenly-occurring active 
congestion of the anterior cornua as the cause of infantile paralysis ; but 
there is that affinity between active congestion and inflammation that they 
may be regarded as having the same pathological effect in this instance, and 
therefore the two theories of a spinal congestion and spinal inflammation may 
be considered as one. It is not improbable that in some of the cases which 
more speedily recover there is simple congestion ; while in the more obstinate 
cases and those with inflammatory symptoms the congestion has passed into 
an inflammation or inflammation was present from the first. According to 
this theory, the atrophy so generally observed in the twelve cases in which 
autopsies were made must be considered a degenerative change resulting from 
the inflammation. That so accurate an observer and so excellent a micro- 
scopist as Robin could detect nothing abnormal in the case which he examined 
was probably due to the fact that the inflammation or congestion abated with- 
out producing any degenerative changes in the nervous substance. 

Professor Charcot regards atrophy of the motor-cells as the cause of the 
paralysis, but it is much more in consonance with the facts to consider the 
cellular atrophy a result than a cause. For how could atrophy, which always 
occurs gradually and by progressive increase, be the cause of a disease which 
begins abruptly and is most intense in the very commencement ? Besides, 
atrophy does not occur without some antecedent disease to cause it. 

In a report to the International Congress at Amsterdam, Drs. Damaschino 
and Roger give the following summary of the result of their recent study of 
the pathology of infantile paralysis : 1 

1. The anatomical lesions are situated in the motor regions of the spinal 
cord. 

2. They consist of a central myelitis, with a stadium of softening and 
atrophic destruction of the cells of the gray substance, together with sclero- 
sis of the lateral columns and considerable atrophy of the anterior roots and 
the nerves leading to the paralyzed muscles. 

3. Atrophy of the cells is not — as Charcot is of opinion — the whole pro- 
cess, as it is in progressive muscular atrophy. 

4. The opinion of Leyden, that there is a circumscribed and diffused mye- 
litis in children, is worthy of consideration. 

It remains for future examination to decide whether the myelitis begins 
as interstitial or parenchymatous in the connective tissue or the nerve-cells. 

Recent observations by Drunmiond (1885), Gowers (1888), and others have 
apparently established the theoiy of Roger and Damaschino — to wit, that 
the paralysis which we are considering results from acute inflammation of 
the gray matter of the spinal cord, and entirely or chiefly of the gray matter 
in the anterior cornua, that of the posterior cornua not being affected. 

All muscular fibres which are in a state of disuse begin in a few weeks to 
atrophy and undergo fatty degeneration. The transverse striae in the primi- 
tive muscular fasciculus gradually disappear, and are replaced by granules 
of fat, and later still by small oil-globules. If we examine with the micro- 
scope the fibres from a muscle which has been a considerable time paralyzed, 
but which has still some electric contractility, we will find in places the striae 
remaining, but numerous opaque granules of a fatty nature within the sarco- 
lemma wherever the striae are absent, and in other places, where the degen- 
eration is most advanced, oil-globules occur, always small. If the paralysis 
be more profound, the striae have all disappeared. At a later stage, usually 
after some years in cases of complete and incurable paralysis, the fatty mat- 
ter may be to a considerable extent absorbed, and the fibrous network of the 
muscle which remains presents a tendinous appearance. There is a great 
1 Le Progres medical, No. 39, 1880. 



POLIOMYELITIS ACUTA ANTERIOR. 



669 



regards 



difference, however, in different cases as 
these changes occur. 

two cases after the lapse of more than four year 
nerves of the paralyzed part also undergo atrophy 



the rapidity with which 



Hammond states that he found the strise remaining in 

of decided paralysis. The 




Figure showing displacement of the humerus in poliomyelitis acuta anterior which came on 
suddenly, and no proper treatment was employed for months. 

Diagnosis.— This is easy as soon as the attention of the physician is 
directed to the state of the limbs. In a large proportion of cases the mother 
or nurse first observes the paralysis and calls the attention of the physician 
to it. A knowledge and recollection of the facts in relation to this paralysis 
should lead the physician to examine the state of the limbs in all cases of 
fever in young children occurring without apparent cause. 

Prognosis. — It may be confidently predicted, if the child be seen early 
and correctly treated, that the paralysis will diminish, if it cannot be entirely 
cured. If the paralysis have continued a considerable time, and there be no 
electric contractility of the muscles, there is poor prospect of any improve- 
ment. The induced current will fail sometimes to cause muscular contrac- 
tion, when the direct current may produce it ; but if there be no response to 
the direct current, there is no therapeutic agent which can restore the use of 
the limb. 

In cases seen soon after the paralysis commences and before the stage of 
atrophy the prognosis is most favorable when there is still slight voluntary 
motion, and improvement commences early. In most instances, even when 
the paralysis has been mild and of comparatively short duration, the extrem- 
ity, although its motion be fully restored, is for a long time weaker than 
before the attack. 



670 LOCAL DISEASES. 

Treatment. — A physician called at the commencement of the paralysis 
should endeavor to remove every cause which might increase the irritability 
of the nervous system. The bowels should be kept open and the diet be 
plain and unirritating. 

Local treatment is very useful at all periods of the paralysis. In the 
first days cold applications, as by an India-rubber bag containing ice, should 
be made over the spine. Stimulating embrocations over the spine and upon 
the paralyzed limb are appropriate after the cold has been discontinued, and 
benefit may also be derived from dry cups along the spine. Ergot, the bro- 
mide and iodide of potassium, which may be administered variously combined 
or singly, are the appropriate remedies for the first twelve or fourteen days. 
Administered every three or four hours in proper dose, they are the most 
effectual of all internal remedies for diminishing spinal congestion and pre- 
venting effusion and permanent structural change in the cord. Unfortu- 
nately, this first stage is in many instances far advanced before proper treat- 
ment is employed to subdue the myelitis, either from an incorrect diagnosis 
or because the physician is not summoned until structural changes have 
occurred, which constitute the second stage. 

If the paralysis continue or if it do not progressively diminish, we should 
not delay more than two weeks from the commencement of the disease before 
employing appropriate measures to restore the use of the limbs and arrest 
atrophy of the muscles. The expectant plan of treatment, which is proper 
in many diseases of children, is unsuited to this. Muscular atrophy may 
commence in three weeks, and the farther it has advanced the more difficult 
and tedious will be the cure. Therefore, by the close of the second week, if 
the paralysis continue or be not rapidly disappearing, iron as a tonic with 
strychnia should be prescribed. There is probably no better formula for the 
exhibition of these agents than the following from Professor Hammond : 

R. Strych. sulphat., gr. j ; 

Ferri p yrophosphat. , gss ; 

Acidi phosphorici dilut., Jss ; 

Syr. zingib., Jfiijss— Misce. 

One-third of a teaspoonful or one-ninetieth of a grain of strychnia is suffi- 
cient for a child of two years, administered three times daily. Hillier, Bar- 
well, and others have employed subcutaneous injections of strychnia, with, it 
is stated, a good result. While in the first and second weeks the child has 
been allowed to remain quiet, he should now be encouraged to use his limbs. 
Frequent muscular contraction must, if possible, be produced, and the volun- 
tary movements, when not totally lost, aid greatly in promoting the nutrition 
of the muscles and restoring their function. Immersing the limb for half 
an hour in water at a temperature of 110° or 115°, rubbing the limb with a 
coarse towel, and kneading the muscles aid also in restoring nutrition and 
tone to them. 

But, fortunately, we have an invaluable agent in the electric fluid, which 
can be made to penetrate the muscles and cause their contraction when every 
other measure has failed. The induced current should be employed upon the 
limb every day or second day if it cause the muscles to act, but if the loss of 
power be of long standing or complete, so that the induced current is not 
sufficiently powerful, the direct current should be used instead. It is not 
regarded as important which way the current passes, provided that the mus- 
cles contract. 

In a large proportion of cases a cure cannot be effected until the lapse of 
several months, so that the patience of the physician and friends may be put 



FACIAL PARALYSIS. 671 

to the test; but if muscular atrophy can be prevented and the limb kept at 
nearly the normal temperature, this mode of treatment will ordinarily in the 
end be successful. The primary affection which caused the paralysis will, 
with some exceptions, be removed by the treatment indicated above, after 
which the state of the muscles and their nervous supply demand the whole 
attention. Observations show that by treatment perseveringly employed 
fatty degeneration of the muscular fibres can be not only arrested, but the fat 
which has already been deposited within the sarcolemma may be absorbed and 
the muscular stride restored. In those cases in which it has been necessary 
to employ the direct current the induced should be used whenever by the 
improvement of the case it is found sufficiently powerful. 



CHAPTER XIY. 

FACIAL PARALYSIS. 

Causes. — Facial paralysis in the new-born commonly occurs from pres- 
sure of the blade of the forceps upon the portio dura at a point external to 
the stylo-mastoid foramen. It may also occur in children of any age from 
exposure of the face to a cold wind. The pressure of a tumor upon some 
part of the portio dura, or even of the fist of the child placed under the face 
during sleep, may cause it. It may also result from disease of the temporal 
bone, producing pressure on the nerve, as caries, periostitis, suppuration, or 
hemorrhage into the aquseductus Fallopii, and also from intracranial disease 
affecting the pons Varolii or the medulla oblongata. 

Symptoms. — The portio dura, which is a nerve of motion, supplies the 
muscles of the face, and therefore its loss of function is at once manifest in 
distortion of the features. The eye of the affected side remains open in con- 
sequence of paralysis of the orbicularis palpebrarum, the upper lid being- 
raised by the levator muscle, which is not paralyzed, since its nerve is derived 
from the third pair. From the inability to wink, the eye becomes irritated 
by dust and constant exposure, and in children old enough to have an abun- 
dant lachrymal secretion the tears are liable to flow over the cheek. On ac- 
count of the paralyzed and relaxed state of the facial muscles the mouth is 
drawn toward the healthy side, while the affected side presents a swollen 
appearance. Movement of the eyebrow or the anterior portion of the scalp 
on the paralyzed side is also impossible, since the occipito-frontalis and cor- 
rugator supercilii are supplied by the portio dura. If the cause of the dis- 
ease is located above the origin of the chorda tympani, the flow of saliva and 
sense of taste on the affected side are impaired. If the injury be posterior to 
the gangliform enlargement, those symptoms are superadded which are due 
to paralysis of the petrosal nerves. 

Figure 193 represents a case which was under observation in the New 
York Infant Asylum. The age of the infant at admission was about five 
months, and its previous history was unknown. The paralysis was perma- 
nent. Death occurred some months later from an intercurrent disease, and 
no cause of the paralysis could be discovered in a careful examination. 

Prognosis. — This depends on the cause. If the cause be peripheral, as 
from the pressure of the forceps or from cold, the prognosis is favorable. In 
case of deep-seated lesion, unless syphilitic, the prognosis is usually unfavor- 
able. A syphilitic lesion can often be removed by appropriate remedies and 
the paralysis be cured. 



672 



LOCAL DISEASES. 



Treatment. — In paralysis of the new-born from pressure of the forceps 
all that is required is occasional rubbing or gentle kneading over the affected 

muscles. In those who are older the nature 
Fig. 193. of the cause, so far as ascertained, must de- 

termine the treatment. If there be glandular 
swellings and discharge from the ear from 
scrofula, cod-liver oil and the syrup of the 
iodide of iron are required internally, with 
appropriate external treatment of the glands 
and ear. If syphilis be the cause, mercurials 
and the iodide of potassium should be em- 
ployed. If the patient do not soon begin to 
improve, the treatment recommended for in- 
\ \ * I? ' ill V fantile paralysis, modified somewhat on ac- 
count of the difference in location, is appro- 
priate. Iron and strychnia may be admin- 
istered internally. The external treatment 
should consist of friction, kneading, hot appli- 
cations, and the electric current. The current should have only moderate 
intensity, for a high degree of it might injure the vision. It should be ap- 
plied every second day, with one pole over the mastoid foramen and the 
other moved slowly over the muscles. 




CHAPTER XV. 



PSEUDO-HYPERTKOPHIC PAEALYSIS. 

This is a rare disease. It was first described by Duchenne in 1861, and 
since the attention of the profession was directed to it, cases have been 
observed on the Continent, in Great Britain, and in this country. Though 
our acquaintance with it is so recent, it has been fully and accurately 
described by various writers in our language. The Transactions of the Lon- 
don Pathological Society for 1868 contain a translated paper relating to it, 
communicated by M. Duchenne, with photographic views and remarks by 
Lockhart Clarke, and also the histories of two cases occurring in London and 
exhibited to the Society by Adams and Hillier. In this country an elaborate 
paper has appeared on this form of paralysis from the pen of Dr. Webber 1 
of Boston, who succeeded in collecting the records of 41 cases ; and more 
recently Dr. Poore, 2 physician to the New York Charity Hospital, collected 
the records of 85 cases, which furnish the material of his monograph. 

Weakness of the legs and a peculiar waddling gait are the first observ- 
able symptoms, and by them we are able to ascertain approximately the date 
of the commencement of the paralysis. In 27 of the cases collated by Dr. 
Poore the malady began so early in infancy that they were never able to 
walk like other children ; in 5 there is no record in regard to the time when 
the peculiar gait was first observed or whether they ever could walk ; 52. or 
about two-thirds of the cases, walked well at first, having no symptoms of 
the paralysis till after the age of two years. In 15 of these, weakness of 
the legs and the peculiar gait were first observed between the ages of two 

1 Boston Med. and Surg. Jour., Xov. 17, 1870. 

2 New York Medical Journal, for June, 1875. 



PSEVDO-HYPERTROPHIC PARALYSIS. 



673 



and a half and five years ; in 23, between the ages of five and ten years ; in 6, 
between the ages of ten and sixteen years ; and in 8, over the age of sixteen 
years. It is seen, therefore, that this malady is pre-eminently one of infancy 
and childhood. 

The gait, which is unsteady and waddling, has been compared to that of 
a duck. The child stands with the legs wide apart, and from the weakness 
of the limbs and unsteadiness of the gait frequently stumbles and falls. In 
many cases this muscular weakness and difficulty in walking occur before 
there is any perceptible enlargement of the muscles beyond the normal size. 

The hypertrophy occurs without tenderness, pain, or other nervous symp- 
toms, and without fever or constitutional disturbance. Occasionally the 
patient complains of stiffness or aching in the limbs, especially after exer- 
cise, even before the enlargement is observed, and exceptionally there is pain, 
even acute, in the legs. The hypertrophy is ordinarily observed first in the 
calf of one leg, and then in the opposite calf. In a case related by Nie- 
meyer the muscles of the gluteal region were first affected. In nearly all 
cases the gastrocnemii are hypertrophied. There were only 2 exceptions in 
the 85 cases collated by Dr. Poore, but almost any of the other muscles or 
groups of muscles may also be involved. The muscles which are most 
prominently affected and which produce the characteristic deformities are 
those of the extremities and posterior aspect of the trunk. Spinal curvature, 
which is attributed to the weakened state of the erector muscles of the spine, 
appears early and is seldom absent. The bending is such that a plumb-line, 
dropped from the most posterior of the spinal processes, falls behind the 
plane of the sacrum ; and this is a means of 
distinguishing this disease from certain other 
spinal affections. Figure 194 represents a case 
which came to the children's class at Bellevue 
in April, 1872. The boy was two years old. 
and the mother stated that the peculiar gait 
and the enlargements had only been observed 
from four to six weeks, and yet the curvature 
of the spine was quite marked. He did not 
return to the class, and his subsequent history 
is therefore unknown. 

Of the muscles in the upper extremities 
the deltoid and scapular are most frequently 
enlarged. Hypertrophy of the temporals has 
been observed in 3 cases, of the masseters in 
2. of the tongue in 3, and of the heart in 4 
(Poore). 

We shall see presently that atrophy occurs 
in the muscular element of the parts which 
are affected, and that the hypertrophy is due 
to hyperplasia of the connective tissue. Now, 
occasionally this hyperplasia does not occur 
or is tardy in occurring, while the atrophy has 
taken place. Therefore, certain muscles may 
have less than the normal volume, which, 
from contrast with those which are hypertro- 
phied, increases the deformed appearance. In 

ordinary cases the enlargement advances more rapidly and continues greater 
in the gastrocnemii, which are, as we have stated, the muscles first affected, 
than in other muscles, and therefore the prominence and hardness of the 
calves of the legs are greater than elsewhere. In advanced cases walking is 
43 




674 LOCAL DISEASES. 

impossible, and the patient is obliged to remain in a reclining posture. Some- 
times from the unequal muscular action the feet become extended and the 
toes flexed, so that the child in attempting to walk steps on the anterior part 
of the sole of the foot, as in talipes equinus. 

In the first stages of the disease the electric contractility of the muscles 
is nearly normal, but in advanced cases response to the galvanic current 
becomes more and more feeble according to the degree of atrophy of the 
muscular fibres. The skin retains its normal sensibility, with exceptional 
instances in which there is numbness either general or in places. Reddish 
or bluish mottling of the surface of the extremities is sometimes observed, 
which is attributed by some to obstructed venous circulation in the hypertro- 
phied muscles, and by others is supposed to be due to the peculiar neuro- 
pathic state. The bladder and rectum are not involved. The mental facul- 
ties are more or less blunted and feeble in certain cases, especially when the 
disease begins in early infancy, but in some patients they do not seem to be 
materially impaired. 

Anatomical Characters. — There have been so few post-mortem exam- 
inations of those who died having this disease that it is still uncertain whether 
there is any centric lesion. Cohnheim examined the spinal cord in one case, 
and could find nothing abnormal. Recently, Mr. Kesteven has examined the 
brain and spinal cord from a case, and found dilatation of the perivascular 
canals both in the brain and spinal cord, and also spots of granular degen- 
eration, chiefly in the white substance, " caused by loss of cerebral tissue 
replaced by morbid matter." l As this child was imbecile, it is not improba- 
ble that these lesions were connected with the mental state and not the mus- 
cular disease. 

Professor Charcot 2 reports a careful microscopic examination of the spinal 
cord and of the nerves in a case which had continued ten years. He could 
discover no deviation from the healthy state. More recently, Dr. J. Lockhart 
Clarke 3 examined a case and found the encephalon healthy, but in the spinal 
cord there was more or less disintegration of the gray substance in each lat- 
eral half, and in places dilatation of vessels and commencing sclerosis. 

It seems, therefore, that central lesions are not essential and are some- 
times absent. When they do occur it is probable that they are consecutive 
to the paralysis. 

The essential lesions in this malady are atrophy of muscular fibres and 
hyperplasia of the connective tissue which surrounds these fibres. The 
hyperplasia of the one element in the muscle is greater than the atrophy of 
the other, and hence the increase of volume above the normal size. The 
atrophy is probably a primary lesion, for muscular weakness ordinarily occurs 
for a considerable time before there is any evidence of the enlargement, and, 
as we have seen, certain muscles may undergo the atrophy without the hyper- 
plasia. Still, the mechanical effect of the newly-formed connective tissue 
doubtless increases the atrophy in those muscular fibres which this tissue 
surrounds, and the comparatively quiet state of muscles in consequence of 
paralysis not only tends to promote the atrophy and degeneration of these 
muscles, but also of contiguous healthy muscles. 

The muscles which are involved in this paralysis present a pale yellowish 
hue, resembling, says Niemeyer, the appearance of lipoma. Examining by 
the microscope, we find, in addition to a large increase in the fibrous tissue 
and atrophy, and in some places disappearance of the muscular element, more 
or less fatty matter, granular and globular, occupying the interstices. Mr. 
Kesteven describes as follows the appearance of the muscles in the case which 

1 Jour, of Med. Sci., Jan., 1871. 2 Archiv. de Physiol, March, 1872. 

3 Medico-Chir. Trans., 1874. 



PSETJDO-HYPERTROPHIC PARALYSIS. 675 

he examined : " The muscular substance is pale, almost white, and very 
greasy. The superabundance of fat is evident to the naked eye. The mus- 
cular fibres present the ordinary striation, but less distinctly than usual. 



Fig. 195. 







'h 









"^^D 






2. Of 



Beginning changes in lipomatous pseudo-hypertrophy of the muscles after Ebstein and Man: 
increase and nuclear proliferation of the interstitial tissue and increase of the sarcolemma 
nuclei : 1 hf, two hypertrophic fibres; 2 af, atrophic fibres. (Enlarged 400 times.) 

The ultimate fibres are pale, and separated by a large increase of areolar and 
fibrous tissue." 

Causes. — Why there is this strange perversion of nutrition, so that there 
is an exaggerated development of the connective tissue of the muscles and 
atrophy of the muscular fibres, is unknown. Boys are more liable to be 
affected than girls. Of the 85 cases embraced in the statistics of Dr. Poore, 
73 were boys, and there was a similar excess of males in the cases collated 
by Dr. Webber. 

There is in a considerable proportion of cases the record of hereditary 
transmission, and in almost all the instances the predisposition is acquired 
from the mother's side. Thus in 37 of Dr. Poore's cases " 2 or more belonged 
to the same family." In some instances three and even four maternal rela- 
tives had this form of paralysis. In one case observed by Duchenne, and in 
a few others subsequently observed, this malady seemed to be congenital, for 
the limbs at birth were unusually large, and the patients when they came 
under observation were unable to walk. No relation has been observed 
between this paralysis and syphilis, scrofula, or other diathetic diseases. 

Prognosis. — This disease is in most instances progressive, terminating 
fatally after a variable period. It is in its nature chronic, rarely ending in 
less than five or six years. A considerable proportion live longer, some even 
attaining adult age. The paralysis may be stationary for a time, but after- 
ward continue to increase. Duchenne has reported one case of recovery. In 
two or three other instances patients appeared to improve somewhat under 
treatment, but the writers admit they may have become worse afterward. 
Death usually occurs, not directly from the paralysis, but from some inter- 
current disease, especially of the lungs. 

Treatment. — The treatment thus far employed has been chiefly local, 
consisting in the use of electricity and kneading or shampooing over the 



676 LOCAL DISEASES. 

affected muscles. Both the primary and induced electric currents have 
been employed, but. unfortunately, without any appreciable benefit in most 
cases. Benedikt. who claims a better result from electrization than any 
other observer, applied the copper pole over the lower cervical ganglion, and 
the zinc pole along the side of the lumbar vertebras by means of a broad 
metallic plate. 



CHAPTER XVI. 

DISEASES OF THE SPINAL COED AND ITS COVERINGS. 

The diseases of the spinal cord and of the parts which cover and protect 
it are important, but they are less understood than are those of any other 
portion of the body. This is partly due to the fact that in many cases the 
spinal disease coexists with a similar pathological state of the brain or its 
meninges, the symptoms of which predominate and mask those which pertain 
to the spine ; partly to the fact that the chief symptoms of spinal disease are 
often located in organs or parts which are at a distance from the spine ; and, 
lastly, to the fact that it is difficult, for obvious reasons, to determine the 
exact state of the spine at the bedside, while post-mortem inspection of the 
spine, which alone can give accurate pathological knowledge, is less frequently 
made than of any other organ. 

Certain spinal diseases occurring in childhood are the same as in adult 
life, presenting identical symptoms and lesions in the two periods, and there- 
fore they require no extended notice in this treatise. Others are common to 
childhood and maturity, but they present peculiarities in the former period 
which require to be pointed out, while others still are peculiar to childhood. 

The so-called spinal irritation or anaemic neuralgia is not infrequent in 
delicate and poorly-fed children. I have from time to time observed marked 
cases of it in the class in the Out-Door Department of Bellevue, the patients 
usually being above the age of three or four years and exhibiting evidences 
of cachexia. Most of them have been spare and pallid, some affected with 
a nervous cough or palpitation, and some with neuralgic pains in the chest, 
abdomen, or elsewhere, which pressure at a certain point upon the spine 
intensified. These cases recover by better feeding, out-door exercise, mild 
counter-irritation along the spine, and the use of tonics, especially of iron. 

Primary inflammation of the cord and its meninges is rare in children. 
Secondary inflammation of these parts is, on the other hand, more common 
in children than in adults. It is common in caries of the vertebras and in 
cerebro-spinal fever. The preponderance in functional activity of the spinal 
cord and the feeble controlling power of the brain render infancy and child- 
hood more liable to convulsions and reflex paralysis than any other period in 
life. Cases of true reflex paralysis occasionally occur in children, in regard 
to the etiology of which there can be no doubt. Prof. Sayre of this city has 
called attention to the fact that balanitis and preputial adhesions sometimes 
cause paraplegia, more or less pronounced, in young children, and which is 
relieved by dividing the adhesions and restoring the mucous surface of the 
glans and prepuce to its normal state. Such a case was brought to the chil- 
dren's class in the Out-door Department at Bellevue in April, 1875. The 
child could not walk or scarcely stand without support, but after the division 
of the adhesions and subsidence of the inflammation, locomotion rapidly 



CONGESTION OF THE SPINAL COBB AND ITS MEMBRANES. 677 

improved. 1 In another instance a child could not walk properly, having a 
tottering gait and dragging one foot. The preputial and urethral orifices 
presented an irritated appearance. The prepuce was stretched and separated 
from the glans at a few sittings, the instrument used being an infant's catheter 
stiffened with a wire, so that it served as a probe. Large masses of smegma, 
nearly as far forward as the preputial orifice, were found underneath. These 
were removed, and the parts were smeared with sweet oil. The patient rap- 
idly recovered the full use of his limbs, and was soon entirely well. It is 
well known that masturbation sometimes causes a similar weakness of the 
lower extremities. Dr. West relates the case of a child " between two and 
three years old " who began to totter in his gait, and finally almost ceased 
walking. He was observed to practise masturbation. " This was put a stop 
to." and he soon recovered his health and his power of locomotion.' 2 



CHAPTER XVII. 

CONGESTION OF THE SPINAL CORD AND ITS MEMBRANES. 

Congestion of the spinal cord and meninges occurs both as a primary 
and secondary malady, the latter being more frequent than the former. It 
may be active or passive. Active congestion, occurring independently of 
meningitis or myelitis, is in most instances transient and subordinate to some 
graver disease, in the course of which it arises. It is probably often over- 
looked. It is not fatal, and its symptoms are frequently masked by those 
which are referable to the brain or some other organ. It is believed to be 
common in the initial period of certain of the fevers of childhood. It is not 
improbable that the hypergesthesia observed upon the thoracic and abdominal 
surfaces and along the thighs in the commencement of remittent and certain 
other febrile diseases has its origin in a congested state of the spine. To 
this congestion writers attribute the lumbar pain and occasional paraplegia in 
the initial stage of variola. Active spinal congestion may also result from 
the sudden impression of cold, and, as we have stated above, this is apparently 
the most frequent cause of poliomyelitis acuta anterior. 

Certain anatomical circumstances favor the occurrence of passive con- 
gestion of the spinal cord and meninges — to wit, the tortuousness of their 
veins and the absence of valves, the lack of muscular support in them, of 
the vessels, and the inferior position of the spine in sickness as the patient 
lies quietly in bed. A common cause of passive congestion of these parts is 
some protracted and enfeebling disease which diminishes the contractile force 
of the heart (cardiac paresis), producing congestion of the spinal cord in the 
same manner as under similar circumstances hypostatic congestion of the 
lungs occurs. Severe convulsive diseases, as tetanus or eclampsia, when pro- 
tracted or occurring at short intervals, commonly produce spinal congestion. 
In tetanus this congestion is extreme, so that extravasation of blood is liable 
to occur from the engorged vessels, especially those of the pia mater. 

Anatomical Characters. — It is often impossible, at post-mortem exami. 

1 Drs. Holgate and Bosley, formerly attending physicians in the children's class at 
Bellevue, made many examinations of the state of the prepuce in young children. 
They report that they found preputial adhesions almost daily, in most instances without 
symptoms, but sometimes with dysuria, and occasionally with more or less impairment 
of the use of the legs. 

rueonwe j Children, p. 146, 4th Amer. ed. 



678 LOCAL DISEASES. 

nations, to determine how much of the congestion of the spine and its meninges 
is pathological and how much cadaveric, since, if the corpse be placed on its 
back at death, a very considerable engorgement of the spinal vessels occurs 
from gravitation of blood. If the body have been placed on the side or face, 
this cadaveric congestion is prevented. Since in active congestion the arterioles 
and capillaries are distended with arterial blood, the color is a brighter red 
than in passive congestion, in which venous blood predominates. Active con- 
gestion of the cord usually coexists with that of the meninges, but it may 
occur without it. In cases of considerable congestion the " puncta vascu- 
losa " appear upon the incised surface both of the white and gray substance. 
If the congestion be protracted or if it recur frequently, it may produce per- 
manent dilatation of the arterioles and capillaries in greater or less degree, 
and it may also lead to sclerosis of the cord. Passive congestion seldom, per- 
haps never, occurs in the cord without being equally and often to a greater 
extent present in the meninges. Continuing for a time, it gives rise to trans- 
udation of serum into the interspaces over the cord, and even softening of 
the cord may occur to a limited extent from imbibition of serum. In either 
form of congestion extravasations of blood are frequent. 

Symptoms. — Spinal congestion is announced by pain in the region of the 
spine, usually in the lumbar or dorsal and lumbar portions, and irradiations 
of pain and tingling in the legs. In addition, more or less paralysis of the 
bladder and legs may result. The paraplegia may occur early or not till the 
lapse of several days. In active congestion the symptoms are rapidly devel- 
oped, and they attain their maximum intensity sooner than in the passive 
form. In passive congestion the development of symptoms is not only more 
gradual, but they are ordinarily less pronounced, and are attended by more 
fluctuation, than in the active form. The paralysis, if present, comes on 
slowly after several days, and is incomplete. Spinal congestion, especially 
of the passive form, is sometimes associated with cerebral congestion — as, for 
example, in tetanus and severe eclampsia — and the spinal symptoms there- 
fore coexist with those which have a cerebral origin. The duration and the 
result of a hyperaemic state of the spinal cord and its meninges depend 
largely on the nature of the cause. If it be not relieved within a few days, 
there is strong probability that some other serious pathological state has 
supervened, as meningitis, myelitis, extravasation of blood, or serous trans- 
udation, with softening of the nervous substance. 

Treatment. — In the adult spinal congestion sometimes results from the 
sudden cessation of the hemorrhoidal or catamenial flow, and the application 
of leeches or wet cups along the spine is indicated. But in the child the 
abstraction of blood is seldom required. In the acute stage of active spinal 
congestion, with elevation of temperature, cold applications along the spine 
are often beneficial, as by an India-rubber bag. 

In active hyperasmia laxatives are useful, and rubefacient applications 
should be made along the spine, as by mustard or by friction with a stimu- 
lating liniment. In the inflammatory spinal congestion of cerebro-spinal fever 
I have employed with a very satisfactory result a liniment containing equal 
parts of camphorated oil and turpentine. In both active and passive hyper- 
asmia lateral decubitus should be prescribed rather than dorsal. The use of 
ergot in order to diminish the turgescence of the vessels of the spinal cord 
and meninges has been advocated by Brown-Sequard, and it is now one of 
the recognized remedies. Bromide of potassium is also a remedy of value, 
but it is more useful in some cases than in others. It is signally beneficial 
in those cases in which there is also cerebral congestion. When the conges- 
tion is increased or produced by clonic convulsions the bromide is one of the 
most reliable remedies which we possess for the removal of the cause. Thus, 



CONGESTION OF THE SPINAL CORD AND ITS MEMBRANES. 679 

it should be employed in the treatment of the spinal and cerebral congestion 
in the commencement of variola, in which convulsions are so common, and in 
the convulsions of pertussis or pneumonia, which cause extreme passive con- 
gestion of the cerebro-spinal axis. Passive congestion of the spine, common 
in exhausting diseases and due to feebleness of the circulation, is best treated 
by stimulating and sustaining remedies and by the lateral decubitus. It is 
hypostatic, and may be associated with a similar congestion in the posterior 
part of the lungs. 



SECTION III. 
DISEASES OF THE DIGESTIVE APPARATUS. 



CHAPTER I. 



SIMPLE STOMATITIS, ULCEKOUS STOMATITIS, FOLLICULAR 
STOMATITIS. 

Diseases of the digestive system are very frequent in infancy and child- 
hood. They are for the most part readily recognized, and are more easily 
and quickly controlled by therapeutic agents, if rightly applied, than are the 
diseases of any other system. If misunderstood and improperly treated, 
they may, even when mild and very manageable in their commencement, 
become chronic and obstinate, or even fatal, or they may lead to other and 
more dangerous diseases. It is necessary, then, that the physician should 
understand thoroughly the pathology as well as the therapeutics of the 
digestive system, that he may make timely and correct use of the required 
remedies. 

The diseases of the buccal cavity in early life are for the most part in- 
flammatory, one of the most interesting of which — to wit, sprue or thrush — 
we have already treated of among the diseases of the newly-born. The 
mildest of these diseases is that known as 

Simple or catarrhal stomatitis, which is more common in infancy than in 
any other period of life ; it occurs over the whole buccal cavity or a portion 
of it, according to the nature of the cause. A common cause is the use of 
indigestible food or food not suitable for the age or development of the infant, 
and therefore irritating ; uncleanliness, personal and domiciliary ; in fine, all 
those agencies which impair the general health and enfeeble the digestive 
organs. Therefore stomatitis is more common among the city poor, who are 
often improperly fed, than in those in the better walks of life, and especially 
those who have the fresh air and properly prepared food of the country. 
Infants deprived of the mother's milk, and given a diet which, with all care 
of preparation, is a poor substitute for the natural aliment, are very liable to 
this disease. Beaumont ascertained from his experiments on St. Martin that 
irritative changes produced in the stomach by indigestible substances were 
soon followed by similar changes in the buccal mucous membrane. Since in 
young infants any kind of artificial food is less digestible than breast-milk, 
it is evident why those who are prematurely weaned or are carelessly fed are 
so liable to stomatitis. This inflammation is also sometimes due to irritating 
substances taken into the mouth, as drinks habitually too hot or too cold. 
Stomatitis is also present in measles and scarlet fever and the other eruptive 
fevers. It then corresponds with the cutaneous eruption, and disappears 
when that subsides. 
680 



SIMPLE STOMATITIS, ETC. 681 

Stomatitis has long been ascribed to dentition. There is uniformly some 
tnrgescence of the gum over an advancing tooth, but in the normal state 
there is not, in my opinion, any decided inflammation from this cause, but 
inflammation may be produced by frequent rubbing of the gum or the chew- 
ing of an artificial nipple or other hard substance. Mercury, in whatever 
form introduced into the system, excreted by the salivary glands and flowing 
over the buccal surface, is an occasional cause. 

Symptoms ; Appearances. — Stomatitis, like other mucous inflammations, 
is characterized by increased redness and more or less thickening of the 
inflamed buccal membrane, by rapid proliferation and exfoliation of epi- 
thelial cells, and by an increased functional activity of the muciparous fol- 
licles. The heat of the mouth is sometimes augmented in an appreciable 
degree. The gums in severe cases are swollen and spongy, and bleed readily 
if rubbed or pressed. The tongue is usually covered with a light fur, and 
the salivary secretion is frequently augmented to such an extent as to dribble 
from the corners of the mouth. Often there is little suffering, but in other 
instances the patients are fretful, experience pain from the contact of solid 
food. and. if nursing, may even wean themselves from dread of pressure of 
the nipple. 

Simple stomatitis is not difficult of detection, provided that attention be 
directed to the mouth. Inspection informs us of its presence and extent. 
A favorable termination may be confidently predicted, unless there be a state 
of marked cachexia or a grave coexisting disease. If circumstances are 
unfavorable, simple stomatitis may terminate in a more severe form, as the 
ulcerous or diphtheritic. 

Treatment. — The physician should endeavor to ascertain the cause, and, 
if possible, should remove it by appropriate medicinal and hygienic measures. 
Sometimes no special treatment is required, as in measles or scarlet fever. 
When the primary affection terminates the stomatitis disappears of itself. 
If there be much fever and fretfulness, it has been the common practice to 
scarify the gums, but this operation is harmful instead of beneficial by in- 
creasing the tenderness. A few doses of bromide of potassium relieve the 
fretfulness. and mucilaginous and mild astringent lotions suffice for the 
catarrh. Borax is a good local remedy used either with honey or with gly- 
cerin and water — one part of borax to three of honey, or a drachm of borax 
to an ounce of water and two drachms of glycerin. A mixture of bismuth 
subnitrate and boracic acid is also a useful topical remedy. With either of 
these agents, in a favorable condition of system, and without any serious 
coexisting disease, the stomatitis is relieved. 

Ulcerous Stomatitis. 

In ulcerous stomatitis the anatomical characters are those of severe simple 
stomatitis, with the additional element which gives it the name by which it 
is designated. 

The inflammation usually begins upon the gums and extends along the 
buccal surface. Little white points soon appear upon the under surface of 
the mucous membrane, producing slight prominence of it. These points, 
which are inflammatory exudations, mainly fibrinous, gradually enlarge. 
Some unite and give rise to large irregular ulcerations ; others remain isolated, 
producing ulcers which are smaller and of more regular shape. There is. 
indeed, no uniformity as regards the size and form of the ulcers. In the 
folds of the buccal membrane they are usually elongated, while inside the 
lips or where the surface is smooth the circular or oval form predominates. 
It is a noteworthy fact that the exudation underlies the mucous membrane. 



682 LOCAL DISEASES. 

obstructing its nutrient vessels, so that the ulcer which results causes destruc- 
tion of the mucous layer and cure is effected by cicatrization. 

Ulcerous stomatitis is usually confined to that part of the buccal surface 
which covers the gums or is in their immediate vicinity, but in some instances 
it aifects nearly every part of the cavity of the mouth. 

If the disease be severe, considerable swelling occurs around the ulcers, 
but the swollen part is soft and cushiony and not very tender on pressure. 
The soft and yielding nature of the swelling serves as a means of diagnosis 
between this disease and the premonitory stage of gangrene, since in the latter 
affection the swollen part is more indurated. 

If the disease grow worse, more ulcers appear, and those already present 
grow deeper and wider and their edges more vascular. 

If, on the other hand, there be improvement, the swelling subsides, the 
ulcers become more clean, their bases approach the level of the mucous mem- 
brane and present a granulating appearance. Finally, the mucous layer is 
reproduced. A considerable time after the ulcers are healed the new mem- 
brane which occupies their site has a redder hue than the adjacent surface. 

Causes. — Ulcerous, like simple, stomatitis is most frequent in the families 
of the poor. Personal uncleanliness, poor food, a residence in apartments 
dirty, humid, or in other respects insalubrious, favor its development. In 
fine, a cachectic condition, however produced, is a common predisposing 
cause. Ulcerous stomatitis frequently occurs when the system is reduced or 
enfeebled by acute diseases, as after the essential fevers and thoracic and 
intestinal inflammations. In protracted entero-colitis of infants it is some- 
times severe and obstinate, and a case in which this complication arises 
usually ends unfavorably. The abuse of mercury is an occasional cause of 
this form of stomatitis, as well as of simple catarrh. Jaccoud states that 
Bergeron established the fact that ulcerous stomatitis is propagated among 
soldiers by contagion, and he adds, " it is very probable that it is the same in 
infants." 

Symptoms. — The symptoms in ulcerous stomatitis are more severe than 
in the simple form. There are more pain, more salivation, and more fretful- 
ness. The ulcerated surface is sometimes very tender, so that there is but 
little sleep. Drinks, unless bland and lukewarm, are painful, and if the ulcers 
be on the lips or the front of the mouth, the infant nurses less eagerly than 
usual, and even with reluctance, sometimes weaning itself. Occasionally 
the submaxillary glands are tumefied, hard, and tender. The breath has an 
offensive odor. In mild cases, in which the stomatitis is of limited extent, 
this odor may scarcely be noticed, but in severe cases it is almost like that 
exhaled from putrid substances. The fever is in most instances, slight. 

Prognosis. — A favorable prognosis may be given unless the patient be in 
a decidedly cachectic condition or there be a serious coexisting disease, under 
which circumstances the case may be protracted. If death occur, it is due to 
the cachexia or to some pathological state quite distinct from the stomatitis, 
most frequently entero-colitis. Ulcerous stomatitis when the ulcers are small 
and the inflammation of limited extent, is of course more easily cured than 
when it is extensive and the ulcers are large. 

This disease is very liable to return unless the general health be good. 

Treatment. — The physician should endeavor to ascertain the cause of 
the stomatitis, and so far as possible should remove the patient from its influ- 
ence. It is often necessary, in order to ensure speedy recovery, to recommend 
a change in regimen, especially as regards diet and cleanliness. If the 
patient live in damp, dark, and dirty apartments, the family should seek a 
better residence, and he should be taken daily into the open air. 

Tonic remedies are generally required. The ferruginous preparations 



SIMPLE STOMATITIS, ETC. 683 

may be advantageously given, or the vegetable tonics, or the two in combina- 
tion. In selecting the internal remedies we must regard the antecedent dis- 
ease, if there be any, which the buccal inflammation complicates and on 
which it depends. For that large proportion of cases in which there is in- 
testinal catarrh the treatment detailed elsewhere for this disease is indicated. 
Bismuth subnitrate, pepsin, and a careful selection of food appropriate for 
the age of the patient are needed. The following mouth-wash, applied with 
a camel's-hair pencil, has seemed to me more serviceable than the chlorate-of- 
potassium mixture which has been commonly employed : 

R. 



Bismuth subnitrate, 


3y; 


Acidi borici, 




Sodii borat., 


da. £j ; 


Mellis, 


gss; 


Aquse destillat., 


q. s. ad :§iv. 



Aphthous stomatitis may occur at any age, but it is most frequent in 
childhood. It is sometimes designated follicular stomatitis, but the disease 
affects the contiguous mucous surface as well as the seat of the follicles. At 
first a vascular injection is observed, and within a few hours a whitish exuda- 
tion occurs immediately under the epithelium and upon the corium in small 
round or oval isolated spots. The smallest of these patches are not larger 
than a pin's head, but most of them have a diameter of one or two lines, 
and they cause slight prominence of the surface. In two or three days the 
exudation softens, and the epithelium which covers it is thrown off, producing 
an ulcer, superficial, without induration of its edges, but sensitive to the 
touch. It heals in one or two weeks, leaving only a reddish spot or stain, 
which soon fades. Sometimes two or more aphthae unite, forming a patch 
and an ulcer of correspondingly large size. The seat of aphthous stomatitis 
is usually the internal surface of the lips and cheeks, the gums, tongue, and 
occasionally the roof of the mouth. 

Causes. — Probably in most instances the exciting cause is some derange- 
ment of the digestive organs which may not be appreciable. We sometimes 
observe this form of stomatitis in cases of diarrhoea. Occasionally, espe- 
cially in spring and autumn, two children in a family are affected at the same 
time, or two or more in a school, so that the disease presents an epidemic 
character. Children surrounded by bad hygienic conditions, as in the tene- 
ment-houses of cities, are more liable to this, as well as other forms of stoma- 
titis, than are children who live in clean and airy localities and have nutri- 
tious and wholesome diet. 

Symptoms. — The constitutional symptoms in a large proportion of cases 
of aphthae are slight. In twelve children affected with the disease Billard 
found the pulse from sixty to eighty beats per minute. 

The ulcers are painful, as is indicated by the cries of the child when they 
are pressed, and its fretfulness. Solid food, and even drinks, unless bland 
and unirritating, are badly tolerated. The salivary secretion is also aug- 
mented. 

In those rare cases in which the ulcers become confluent or gangrenous 
the state of the patient is really serious. There is then often gastrointes- 
tinal disease. The symptoms indicate prostration. The pulse is feeble, the 
countenance pallid, and the body and limbs become wasted. 

Diagnosis. — This is easy. The only disease with which it is liable to be 
confounded is ulcerous stomatitis. In the ulcerous form there is antecedent 
and accompanying stomatitis affecting a considerable part, if not the entire 
buccal cavity, while in the follicular form the inflammation is ordinarily con- 
fined to the immediate vicinity of the ulcers. The character of the ulcers 



684 LOCAL DISEASES. 

serves also as a means of distinction. In ulcerous stomatitis there is great 
variety as to size and form, while in aphthous stomatitis there is great uni- 
formity in both these respects. The small circular ulcers are characteristic 
of the follicular inflammation. Before the ulcerative stage the circumscribed 
character of the eruption serves to distinguish this form of stomatitis from 
other local diseases affecting the cavity of the mouth. 

Prognosis. — Aphthous stomatitis usually ends favorably, but if the 
ulcers became concrete or gangrenous the health is seriously affected, and a 
more cautious prognosis should be expressed. The unhealthy appearance of 
the mouth and the real danger are more often due to the depressing effect 
of some concomitant disease than to the stomatitis. 

Treatment. — In ordinary aphthous stomatitis, which is discrete and 
attended by little or no constitutional disturbance, local remedies suffice to 
cure the disease. Demulcent drinks or applications to the mouth should be 
used, as the mucilage from gum acacia, marshmallow, or flaxseed. Mild 
astringent lotions with the demulcent are also beneficial. The mel boracis 
is one of the best and most agreeable applications. It may be placed in the 
mouth with a spoon or applied with a camers-hair pencil. If there be much 
tenderness of the ulcers, with restlessness, a small quantity of some opiate 
should be added to the lotion or it may be administered separately. 

With this simple treatment the ulcers generally soon heal and the health 
of the patient is restored. If, however, the ulcers be painful and not dis- 
posed to heal, or be healing tardily, they may be touched lightly with a 
pencil of nitrate of silver, or, as Barrier recommends, hydrochloric acid in 
honey of roses. This diminishes the tenderness and expedites the healing 
process. A better remedy is iodoform, two drachms to one ounce of ether, 
and applied to the ulcers by a camefs-hair pencil. 

If, as may in rare cases occur, the ulcerations be numerous and accom- 
panied by considerable fever, there may be symptoms indicative of cerebral 
congestion or even premonitory of convulsions. In such cases laxatives and 
the soothing effect of one of the bromides, and sometimes of the warm foot- 
bath, are required. 

If there be an unhealthy appearance of the ulcers, if they gradually en- 
large or become concrete or gangrenous, indicating a cachectic state, tonics 
should be employed, with nutritious and easily-digested diet, and antihygienic 
influences should so far as possible be removed. 



CHAPTER II. 

GANGKENE OF THE MOUTH. 

The diseases of the mouth which we have been considering are attended 
by little danger, but the one which we are next to consider is among the 
most fatal of early life. It is gangrene of a portion of the cheek or gums, 
or of both. It is described by writers under various names, as cancrum 
oris, noma, necrosis infantilis, aqueous cancer of infants. 

Anatomical Characters. — Gangrene of the mouth is sometimes pre- 
ceded by ulceration of the mucous membrane at the point where it is about 
to commence, but in other cases this membrane is entire. The tissues at the 
point of attack, which is most frequently the inside of the cheek, become 



GANGEENE OF THE MOUTH. 685 

inflamed, thickened, and indurated. The induration extends, and soon the 
purple hue of gangrene appears and increases. The next stage in the prog- 
ress of gangrene is sloughing of the portion the vitality of which is lost. 

The slough does not present the appearance of uniform decay. While 
the color is generally dark, there are in the mass, fibres of connective tissue, 
or even blood-vessels, which remain unchanged or are but partly decomposed. 
After separation or sloughing of the part where the vitality is first lost, the 
surface of the excavation, if the disease be not checked, has a dark, jagged, 
and unhealthy appearance. Commencing with the mucous membrane and 
the tissue immediately underlying it, the disease extends on the one side 
toward the skin and on the other toward the deeper-seated structures of the 
jaw. According to Billard, the swelling which precedes and surrounds the 
gangrene is in great part ©edematous. 

This disease is occasionally primary, but in a large proportion of cases it 
is secondary. Occurring secondarily, its symptoms are often masked by 
those of the antecedent and coexisting affection. Under such circumstances 
attention is sometimes first directed to the mouth by the loosening of one or 
more of the teeth or the appearance on the skin of a livid circular spot 
which indicates the approach of the disease to the cutaneous surface. The 
mucous membrane presents a dark-red appearance to the distance of a few 
lines beyond the point of gangrene. It covers tissues which are inflamed 
and indurated and about to become gangrenous. 

The tongue is usually more or less swollen, unless the disease be mild ; 
an offensive odor arises from the gangrene, due to the evolution of sulphur- 
etted hydrogen and other gases. There is great difference in the extent of 
the destruction and the gravity of the disease in different cases. It may 
sometimes be arrested by proper applications and a favorable change in the 
general health of the child at an early period, when there is little loss of 
substance. In other cases it extends till it perforates the cheek or even 
destroys a considerable part of the side of the face, and, extending inward, 
attacks the periosteum of the maxillary bone, destroying the gum and teeth 
and denuding the alveoli. Kecovery, if it take place at all under such cir- 
cumstances, is with the loss of a portion of the bone and with deformity. 

The duct of Steno is sometimes included in the. gangrenous portion, but 
it commonly resists the destructive process and remains pervious. 

Age. — The age at which gangrene of the mouth occurs is usually between 
two and six years. In 29 cases collated by Rilliet and Barthez, 21 were 
between the ages of two and six years, and the remaining 8 between six and 
twelve years. Of the cases which have fallen under my observation, most 
were between the ages of two and six years. It is seen that the period of 
greatest frequency of gangrene of the mouth is different from that in which 
the ordinary forms of stomatitis occur, 

Gangrene of the mouth may, however, occur under the age of one year. 
Billard reported 3 cases under the age of one month, but in 2 of these the 
disease does not appear to have been sufficiently marked to render it certain 
that they were genuine cases. 

Causes. — Gangrene of the mouth usually occurs in those whose systems 
are reduced or cachectic. It is therefore more frequent among the poor than 
those in comfortable circumstances — in the city than in the country. It is 
more frequently observed in asylums for children than in private practice. 
Most of the cases which I have seen have been in these institutions. If the 
constitution be good, it can only occur in those long deprived of pure air and 
wholesome nutriment or those enfeebled by disease. 

Among the diseases which have been known to terminate in or be followed 
by gangrene of the mouth are the pulmonary and intestinal inflammations. 



686 LOCAL DISEASES. 

whooping cough, and the fevers, both eruptive and the non-eruptive. Rilliet 
and Barthez have published a table of 98 cases in which gangrene resulted 
from various diseases. In 49 of these the antecedent disease was measles, 
in 5 scarlet fever, 6 whooping cough, 9 intermittent fever, 9 typhoid fever, 
7 mercurial salivation, and 5 enteritis. It is seen that the essential fevers 
were the most frequent cause of the gangrene. Of 46 cases collected by 
MM. Bouley and Caillaut, the antecedent disease was measles in all but 5. 
In this city also a larger number result from measles than from any other 
disease. 

One reason why so many cases of gangrene occur as a sequel of measles 
is probably because this disease is accompanied by stomatitis. Simple or 
ulcerous stomatitis often precedes gangrene. 

Diseases sometimes terminate in gangrene of the mouth in consequence 
of injudicious treatment which has lowered the vitality of the system. Ril- 
liet and Barthez mention the case of a child four years old in whom gangrene 
commenced at the twenty-ninth day of primitive pneumonia. The child had 
been reduced by the application of twelve leeches, three scarifications, a large 
blister, and by a poor diet. 

The misuse of mercury was once a much more frequent cause of gan- 
grene than at present, at least in this country, since this agent was formerly 
much more employed than now. In fact, most of the affections of infancy 
and childhood in which mercurials were formerly employed are now treated 
without it. 

Symptoms. — Gangrene of the mouth so often occurs in connection with 
other diseases that its symptoms are in a large proportion of cases blended 
with those which arise from a distinct pathological state. 

There is usually prostration, more and more pronounced as the gangrene 
extends. The features are ordinarily pallid, but occasionally their normal 
color is preserved for a time ; the expression of the face is melancholy, but 
composed. Sometimes the child is fretful if disturbed ; at other times it 
will quietly consent to an examination. The suffering is not proportionate to 
the gravity of the disease. There is less pain often than in some of the forms 
of stomatitis which are unattended with danger. 

As the disease advances the body and limbs gradually waste, the eyes are 
hollow, or, if the gangrene be near the orbit, the eyelids become oedematous ; 
the lips are infiltrated ; and both the lips and nostrils are often incrusted. If 
the cheek be perforated, alimentation is rendered difficult, and the appearance 
of the child is melancholy in the extreme. 

The tongue is usually moist ; it is occasionally swollen. The saliva flows 
from the mouth, either pure or mixed with offensive sanguinolent matter. 
Unless the disease be slight there is the peculiar gangrenous odor. The 
appetite is sometimes poor ; at other times it is preserved through the whole 
sickness. There is no vomiting or looseness of the bowels, unless from a 
complication. The thirst is usually great, and the pulse is accelerated and 
feeble except in mild cases. 

The skin in the commencement of gangrene is hot. When the vital force 
is much reduced, and especially as the disease approaches a fatal termination, 
the face and limbs become cold and the surface generally presents a waxen 
or ashy appearance. No derangement occurs of the respiratory system. 
Those cases which are attended by a cough or accelerated respiration are 
really cases of bronchitis or pneumonia coexisting with the gangrene. 

Diagnosis. — Gangrene of the mouth is easily diagnosticated. In those 
cases in which ulceration precedes the gangrene it may be mistaken in its first 
stage for that form of ulcerous stomatitis in which the ulcers assume an 
unhealthy appearance. The following are the distinguishing features of the 



GAXGREXE OF THE MOUTH. 



687 



two affections : Around the ulcer where gangrene is about to commence the 
tissues are greatly thickened and indurated or oedematous, while ulcerous 
stomatitis begins with a submucous deposit of fibrin, and is attended by little 
thickening of the surrounding parts and little or no induration or oedema. In 
ulcerous stomatitis the skin over the seat of the disease presents its normal 

Fig. 196. 




appearance, whereas in gangrene it presents a distended and shining appear- 
ance. The destructive process in ulcerous stomatitis is also more limited 
than in gangrene. Deep ulcerations do not occur or are rare. Ulcerous 
stomatitis is more readily healed, and it leaves no eschar, contraction, or 
deformity. 

The differential diagnosis of gangrene of the mouth from those cases of 
follicular stomatitis in which the ulcers occupying the seat of the follicles 
assume a gangrenous appearance must be made by a consideration of the 
same facts or particulars which serve to distinguish it from ulcerous 
stomatitis. 

Malignant pustule, of rare occurrence in the child, resembles this disease 
in some of its features. But the pustule always begins on the skin, while 
gangrene is a disease of the mucous surface primarily. In gangrene, there- 
fore, the chief destruction is of the mucous membrane and of the submucous 
tissue, while in malignant pustule the chief destruction is of the skin and the 
subcutaneous tissue. 

Prognosis. — This depends not only on the extent of the gangrene, but 
the nature of the disease, if there be one, which gave rise to it, and the 
degree of cachexia. If it occur in connection with or as a sequel to one 
of the less debilitating diseases, and there be considerable vigor of system, 
it may often be arrested when it has destroyed only the mucous and sub- 
cutaneous tissues, so that no deformity results. The friends may congratu- 
late themselves if the case terminate so favorably. In the graver cases, when 
the gangrene extends until it destroys the periosteum of the maxillary bone 



688 LOCAL DISEASES. 

on the affected side, and perhaps perforates the cheek, if the child recover it 
is with the permanent loss of teeth, tedious separation of the necrosed bone, 
and a cicatrix which may interfere with the free use of the jaw. Death is, 
however, the more common termination of severe cases. Occasionally the 
gangrene destroys the continuity of a blood-vessel, causing abundant hem- 
orrhage and accelerating the fatal result. In most cases, however, there is 
little or no hemorrhage in consequence of coagulation in the vessels. 

Another serious complication sometimes arises — to wit, gangrene of other 
parts, as of the external genital organs. The English editor of Bouchut's 
treatise on diseases of children relates the following interesting case, from 
the Transactions of the Edinburgh Medico- Chir. Society: An infant eight 
months old became affected with gangrene of the face, head, and hands. 
" The right ear and the entire hairy scalp were of an intensely black color, 
and on both cheeks patches existed about the size of a half-crown piece. 
The right thumb and the backs of both hands were similarly affected. The 
child was noticed to have been restless and feverish on May 22d, and on the 
23d a slightly darkened ring was found to have formed round the thumb, 
about the middle of the first phalanx ; in a few hours the whole thumb was 
gangrenous, and the dorsum of the hand became involved. On the ear the 
gangrene commenced with the appearance of a flea-bite, and subsequently 
extended rapidly to the scalp, assuming a remarkably regular form and 
giving to the child the appearance of wearing a black skull-cap. The pulse 
was observed to be very feeble. .... Death took place in twelve hours from 
the first appearance of gangrene on the thumb, the child being sensible and 
continuing to suck well up to a few minutes before death." 

Rilliet and Barthez state that pneumonitis frequently occurs in the course 
of gangrene of the mouth. Such a complication evidently diminishes materially 
the chance of recovery. 

Whether the result be favorable or unfavorable, it is evident from the nature 
of the disease that the duration is very different in different cases. The phy- 
sician's attendance may be required for a week or two or for several weeks. 

Treatment. — As gangrene of the mouth is eminently a disease of debility, 
all antihygienic influences should be removed and the most nourishing diet, 
together with tonics, be recommended. The ferruginous preparations or the 
bitter vegetables are required. 

As soon as the physician is called he should endeavor to arrest the 
gangrene, accelerate detachment of the slough, and produce a healthy and 
granulating state of the surrounding tissues. This is best effected by apply- 
ing a highly stimulating or even escharotic agent to the inflamed surface 
underneath and around the gangrene. For this purpose a great variety of 
substances have been used by different physicians, such as acetic, sulphuric, 
nitric, and hydrochloric acids, nitrate of silver, the acid nitrate of mercury, 
chloride of antimony, carbolic acid, and even the actual cautery. 

A safer, less painful, and in many cases successful treatment is that 
employed by many British and American physicians — to wit, the use of 
escharotic agents diluted, or, if applied in their full strength, such as are 
least active and penetrating. Some employ from the first topical treatment 
which is astringent and stimulating rather than escharotic, and they report 
satisfactory results. 

Dr. Gerhard believes " the best local applications are the nitrate of silver, 
if the slough be small in extent ; if much larger, the best escharotic is the 
muriated tincture of iron, applied in the undiluted state. After the progress 
of the disease is arrested the ulcer will improve rapidly under an astringent 
stimulant, such as the tincture of myrrh or the aromatic wine of the French 
Pharmacopoeia." 



GANGRENE OF THE MOUTH. 689 

The local treatment recommended by Evan son and Maunsell differs from 
that advised by any of the writers from whom I have quoted. A knowledge 
of this treatment, from which I have myself seen good results, will be best 
imparted by quoting from these authors : l " The lotion which we have found 
by far the most successful is a solution of sulphate of copper as employed by 
Coates in the Children's Asylum. His formula is as follows : 

R. Cupri sulph., gij ; 

•Pulv. cinchona?, 5ss ; 

Aquae, 5iv. — Misce. 

This is to be applied twice a day very carefully to the full extent of the 
ulcerations and excoriations. The addition of the cinchona is only useful by 
retaining the sulphate of copper longer in contact with the edge of the gums. 
A solution of the sulphate of zinc, gj to an ounce of water, by itself or com- 
bined with tincture of myrrh, Dr. Coates found to be also useful in some 
cases." 

A moment's reflection will show us that the above treatment is preferable, 
provided that it is equally effectual in arresting the gangrene, to the treat- 
ment by the strong acids which are in common use, and the efficiency of 
which cannot be questioned. 

The purpose in applying the acid is to establish a healthier state of the 
tissues. It cauterizes and destroys whatever soft tissues it comes in contact 
with ; besides, it produces a strong corrosive action on the teeth and bone. 
Therefore in gangrene affecting the jaw there is great danger that it will 
destroy the periosteum, and consequently increase the necrosis. 

Dr. West, 2 who advocates the use of the acid, says : " In one of the cases 
that I saw recover the arrest of the disease appeared to be entirely owing to 
this agent, though the alveolar processes of the left side of the lower jaw, 
from the first molar tooth backward, died and exfoliated, apparently from 
having been destroyed by the acid." No such result follows the use of the 
solution of sulphate of copper. 

In one of these severe cases in which the disease resulted from scarlet 
fever, and in which there was so much debility that an unfavorable prog- 
nosis was made, I succeeded in arresting the disease by the use of Dr. 
Coates's prescription. The child recovered with the loss of two teeth and 
the corresponding portion of the maxillary bone. From the good effects 
which I have observed from iodoform as an application for gangrenous vul- 
vitis following measles, it has occurred to me that it may also be useful in 
gangrene of the mouth. 

If, after employing the milder treatment for two or three days, the gan- 
grene continue to spread, the strong muriatic acid should be cautiously 
applied by a camel's-hair pencil or small swab in such a way that it comes in 
contact only with the diseased surface. Its use should be immediately fol- 
lowed by an alkaline wash, as a solution of sodium bicarbonate. 

In 1881 an epidemic of measles occurred in the New York Foundling 
Asylum during the attendance of Drs. O'Dwyer and Lee. The number of 
children affected with it was 165, and, since many of them were cachectic. 
we were not surprised that gangrene appeared as a complication or sequel in 
7 cases. In a girl of three and a half years it appeared upon the upper 
jaw at the base of the teeth; in two girls of four years it appeared upon 
the inside of the cheek and upon the vulva, and not upon the gums ; in a 
boy of three years it attacked the lower jaw, destroying four teeth with 
their sockets, and the upper jaw, destroying five teeth, with the correspond- 

1 Diseases of Children, 2d Amer. ed., p. 188. 2 Ibid. y 4th Amer. ed. 

44 



690 LOCAL DISEASES. 

ing portion of the maxillary bone, so that all the incisors and one canine 
were lost, as well as the cartilaginous portion of the nasal septum. Gan- 
grene also occurred in the groin in this case. Another boy of three and a 
half years lost two incisors from gangrene of the jaw. The treatment by 
muriatic acid was employed, and, according to the house physician, Dr. Kort- 
right, there was no further extension of the gangrene after the first applica-' 
tion in any of the cases. All lived except the first, Who had broncho-pneu- 
monia. The remaining two patients, aged respectively four years, died of 
diphtheria and pneumonia before treatment could be tested. One of them 
had commencing gangrene of the lower jaw, the other of the soft palate. 
Recently, in the Foundling Asylum carbolic acid has been used as an eschar- 
otic in one or two cases, instead of the strong acid, and with such a result 
as to encourage its further use. 

The gases arising from the gangrenous mass are not only highly offensive 
to others, but they are doubtless injurious to the patient, who is constantly 
inhaling them. To remove the fetor, chlorine or carbolic acid, properly dilu- 
ted, should be occasionally used between the applications of the sulphate of 
copper. Labarraque ; s solution, one part to eight or ten parts of water, is an 
eligible form for its use. When the gangrene is removed and the granula- 
tions present a healthy appearance, all danger is usually past and convales- 
cence is fully established. Then no energetic topical treatment is required. 
A mild stimulating lotion, like the tincture of myrrh, as recommended by 
Dr. Gerhard, suffices, with the aid of tonics and nutritious diet. 

Efflorescence, Furring, and Eruptions upon the Tongue. 

From time immemorial the physician has inspected the tongue of the 
patient in order to determine his or her physical condition and obtain aid in 
diagnosis. Elevation of temperature, whatever the cause, persisting a few 
hours, indigestion, as Beaumont has shown, and many maladies, not only 
those located in the digestive system, but in organs distantly connected with 
this system, cause a fur to collect on the tongue. Hence from the infancy 
of medicine until the present time the tongue has been inspected by the 
physician before he announced the diagnosis. The fur occurs on the dorsum 
of the tongue, and not on its under surface, and scantily or not at all on its 
borders. It consists of epithelial cells of varying thickness, brown and dry 
in severe and malignant diseases, and of a light-yellow color and moist from 
the secretion of mucus in diseases of a milder type. 

An occasional " circinate eruption " upon the dorsum of the tongue has 
attracted the attention of various observers from the time of Gubler (article 
" Bouche," 1869) until the present time. It begins as a light-colored patch 
and enlarges peripherally. It forms a ring or series of rings resembling the 
ringworm, the interior of which presents a reddish appearance, contrasting 
with the thickened epithelium which forms the rings. In some instances, 
from intersection of the rings, arches are formed. As the circles extend the 
epithelial layer is restored in their centres and the disease gradually disap- 
pears. Most cases occur in infants, and the disease is of little clinical im- 
portance. Cases which I have observed are without pain or other symptom, 
and the patients recovered without treatment. This malady has the appear- 
ance of being microbic, but its origin is uncertain. It is probably best treated 
by antiseptic washes and gargles, as a wash of listerine or Seller's tablet. 



DENTITION. 691 

CHAPTER III. 
DENTITION. 

The opinion formerly entertained in the profession, and now prevalent in 
the community, that many infantile maladies arise directly or indirectly from 
dentition is erroneous. Still, there are physicians of experience who believe 
that teething is a common cause of certain maladies, especially of functional 
derangements, even of organs remote from the mouth. On the other hand, 
equally good observers — and the number is increasing — almost wholly ignore 
the pathological results of dentition. They say that as it is strictly a phys- 
iological process, it should, like other such processes, be excluded from the 
domain of pathology. 

A moment's reflection will show how important it is to understand the 
exact relation of dentition to infantile diseases. Every physician is called now 
and then to cases of serious disease, inflammatory and non-inflammatory, which 
have been allowed to run on without treatment, in the belief that the symp- 
toms were the result of dentition. I have known acute meningitis, pneumo- 
nia, and entero-colitis, even with medical attendance, to be overlooked, and 
the symptoms attributed to teething during the very time when appropriate 
treatment was most urgently demanded. Many lives are lost from neglected 
entero-colitis, the friends believing the diarrhoea to be symptomatic of denti- 
tion, a relief to it, and therefore not to be treated. Such mistakes are trace- 
able to the erroneous doctrine, once inculcated in the schools, and still held 
by many of the laity, that dentition is directly or indirectly a common cause 
of infantile diseases and derangements. 

I shall endeavor to point out what is really ascertained in regard to the 
pathological relations of dentition. 

The first dentition commences at the age of about six months and termi- 
nates at the age of two and a half years. The corresponding teeth of the 
two sides pierce the gum at about the same time. The two inferior central 
incisors first appear at about the age of six or seven months, followed, in the 
order in which they are mentioned, by the upper central incisors, upper lat- 
eral incisors, lower lateral incisors, the four anterior molars, the four canines, 
and, lastly, the four posterior molars. 

The incisors usually appear in rapid succession, so that all are in sight by 
the age of one year. From the age of one year to eighteen months the 
anterior molars appear, and from the age of sixteen to twenty-four months 
the canines, and from twenty-four to thirty months the posterior molars. 
This order is not always preserved. Sometimes the upper central incisors 
appear before the lower, and sometimes the lower lateral before the upper 
lateral. In rare cases there have been teeth at birth. I have seen but one 
or two infants with such premature dentition. Retarded dentition is much 
more common. Those who have rickets or are feeble either constitutionally 
or by disease often have no teeth till considerably after the usual period. 
In such the first incisors may not appear till the age of twelve months, or 
even later. 

Pathological Results of Dentition. — The evolution of the teeth is 
commonly attended by more or less turgescence around the dental bulbs. 
This is greater with some of the teeth than with others. Thus the superior 
incisors cause more swelling than do their congeners of the inferior jaw. The 
turgescence, although attended by more or less congestion, is physiological 
within certain limits, and not a disease. 



692 LOCAL DISEASES. 

But exceptionally there is an unusual amount of swelling around the 
dental follicles ; the afflux of blood to them is greatly augmented ; they are 
the seat of such a degree of tenderness and pain that the infant is fretful. 
It carries the finger often to the mouth, indicating the seat of its suffering. 
The surface over the follicles presents greater redness than in ordinary den- 
tition, and the salivary secretion is considerably increased. There may now 
be actual gingivitis, but such cases are rare. 

Occasionally the turgescence affects a greater extent of the buccal sur- 
face than that lying directly over the follicles, so that most writers speak of 
stomatitis as one of the results of dentition. In a few cases I have known 
such a degree of inflammation over the advancing tooth that a small abscess 
formed, producing pain and restlessness till it was opened by the lancet. 

The pathological results of dentition which I have mentioned, though they 
may interfere more or less with nursing or feeding, are not dangerous. They 
are easily detected. They result directly from the rapid growth and aug- 
mented sensitiveness of the dental follicles. 

There are other supposed accidents of dentition occurring in distant parts 
of the system in consequence of the relation and interdependence of organs 
which exist through the system of nerves. 

Some children prior to the eruption of the teeth are affected with diar- 
rhoea, occasionally accompanied by irritability of the stomach. Certain writers 
have supposed that gastro-intestinal catarrh is present in these cases ; others 
that there is simply a hypersecretion, an increased activity of the intestinal 
follicular apparatus — that it is, in other words, one of the forms of non- 
inflammatory diarrhoea. Barrier believes that the diarrhoea of dentition 
depends usually on what he calls a " subinflammatory turgescence limited to 
the gastro-intestinal follicular apparatus." He believes that in occasional cases 
it is due to defective or altered innervation. It would then be analogous or 
similar to that form of diarrhoea which occurs in the adult from the emotions. 
Bouchut calls the diarrhoea of dentition nervous diarrhoea. It is certain, 
however, that in most cases of diarrhoea which are attributable to dentition 
there are other causes, such as unsuitable food or residence in an insalubrious 
locality. It is certain, as regards city infants, that the chief causes of diar- 
rhoea during the period of dentition are strictly antihygienic, dentition being 
quite subordinate as a cause, and probably ordinarily not operating at all as 
such. But when, as sometimes happens, at each period of dental evolution 
the infant is affected with diarrhoea, the influence of teething is apparent. 
Such cases give rise to the belief that teething may really sustain a causal 
relation to certain diseases not located in the buccal cavity. 

Among the more common pathological results of difficult dentition are 
certain affections referable to the cerebro-spinal system. Eclampsia is one 
of the admitted results. Barrier attributes convulsions in the teething infant 
to excitement of the nervous system arising from the pain which is felt in 
the gums, and to a determination of blood to the dental apparatus, in which 
afflux the whole vascular system of the head participates. 

In most cases of convulsions, occurring during the period of dental evolu- 
tion, a careful examination discloses other causes in addition to the state of the 
gums. Difficult dentition must then be considered not so frequently a direct 
as perhaps a co-operating or predisposing cause, producing a sensitive state 
of the nervous system, or possibly an afflux of blood to the head, of which 
Barrier speaks, and which by an additional stimulus, perhaps trivial in itself, 
ends in convulsions. The belief is not unreasonable that convulsions may 
result when several teeth penetrate the gum at or about the same time. In- 
fants who are burned or scalded are very liable to clonic convulsions. This 
is, in fact, the chief danger as regards life from such accidents. So the 



DENTITION. 693 

swollen and tender gmn, if several teeth are about emerging, may possibly 
affect the cerebro-spinal system like tlie burn or scald and produce the same 
nervous phenomena. Thus in a case already alluded to in the chapter on 
Convulsions, live incisors pierced the gum within about two weeks, and in 
this period there were two attacks of eclampsia with an interval of a few 
days. The attacks were not severe, and the most careful examination could 
reveal no other cause than the simultaneous development of so many den- 
tal follicles. Previously and since the infant has been well. 

Dentition sometimes, though rarely, occasions also tonic contraction of 
certain muscles. The following case occurred in the practice of the late Dr. 
A. S. Church of this city, the history of which he communicated, as follows : 

Case. — " H , seven months old, was first visited April 3, 1863. The patient 

had been fretful for several days, but about daylight on the morning of my first 
visit it commenced crying, and had not ceased for a moment at the time of my visit, 
9 a. m. The bowels were somewhat constipated and tympanitic ; abdominal mus- 
cles very tense. The pain was supposed to be in the abdomen, and a brisk cathar- 
tic, to be followed by an anodyne, was ordered. Some relief followed, but on the 
ensuing and for several consecutive mornings the pain returned, each day lasting 
longer, until the child only ceased crying while under the influence of a full ano- 
dyne. The gum over the upper incisors was considerably swollen, hot, and dry, 
but the parents would not consent to have it scarified. For the first week there 
was no fever, no vomiting, and not the least indication that the nervous system was 
suffering. About the 10th the thumbs were noticed to be flexed during the attack 
of pain, and about the 15th the flexors of the toes were contracted and the hands 
were turned backward and outward, but only while the child was awake. About 
the 20th there was constant contraction of the flexors of both extremities, with 
opisthotonos, and constant rolling of the head, loss of appetite, progressive emacia- 
tion, coated tongue, and highly-inflamed gums. Consent was finally obtained to 
relieve the inflamed gum, and free incisions were made, and the following night the 
child slept comfortably for three hours without opiates. In three days the gums 
were freely cut again, and the teeth soon made their appearance. All symptoms of 
disease had now ceased, the child became playful, and on the 30th the patient was 
discharged." 

More recently a child of about eighteen months, seen by me in consulta- 
tion, had tonic contraction of the flexors of the left thigh and leg, continuing 
nearly a month, so that the thigh was flexed on the body and the leg on the 
thigh. The infant was cutting five teeth at the time, and the gums were 
considerably swollen over them. The normal state of the affected limb 
returned after these teeth had penetrated the gum. 

The opinion has been prevalent in the profession that painful and dif- 
ficult dentition is one of the chief causes of infantile paralysis, but it is now 
admitted that it is only a subordinate or remote cause, if indeed it is proper 
to consider it a cause at all. (See art. Paralysis.) 

The older writers sometimes expressed the opinion that acute meningitis 
occasionally results from teething. The facts, however, that are relied upon 
to prove this are uncertain. The occurrence of meningitis during dentition 
is probably in most instances merely a coincidence. 

Teething does not often disturb the respiratory system. A cough occurs 
in some infants at each period of dental evolution. It is attended by little 
expectoration, but is sometimes associated with an inflammatory turgescence 
of the bronchial mucous membrane. 

Eczema and certain other cutaneous diseases, as well as acceleration of 
pulse and more or less fever, are common during dentition, but their depend- 
ence on it as a cause has not been demonstrated. 

Diagnosis. — The accidents of dentition which are located in the mouth 
are easily diagnosticated, except the odontalgia which writers describe, and 



694 LOCAL DISEASES. 

which is not necessarily attended by any perceptible anatomical alteration of 
the gums. Those accidents which pertain to remote and concealed organs 
are usually detected with ease, though it is often difficult to determine with 
certainty their relation to dentition. It is certain, as the nature of diseases 
becomes better understood, dentition becomes less and less important as an 
etiological factor. 

Treatment. — It is obvious that remedial measures in cases of difficult 
dentition must be twofold — namely, those directed to the state of the gums, 
and those designed to relieve the derangements or diseases to which denti- 
tion has given rise. If there be diarrhoea, this should be controlled by 
proper remedies, so as to reduce the number of evacuations to two or three 
daily. It is well to state to the friends of the child who believe that 
diarrhoea is salutary during the period of teething that this number is 
quite sufficient, and that more frequent evacuations endanger the safety of 
the child. 

The nervous affections, as convulsions, require such soothing and deriva- 
tive measures as are recommended in our remarks on Diseases of the Nervous 
System. The bromide of potassium I have found especially useful and safe 
in cases of fretfulness and nervous excitement during the period of dentition 
and perhaps having dentition as the cause. Demulcent and soothing lotions 
are sometimes useful in cases of painful dentition, and the infant may be 
allowed to hold in its mouth an India-rubber ring, which seems to give con- 
siderable relief. 

Mothers often attempt to c: rub through a tooth," as they term it, by 
means of a ring or thimble. This should be forbidden. So great friction 
cannot fail to have an injurious effect by increasing the swelling and inflam- 
mation, unless the tooth have already reached the mucous membrane. 

We come now to a subject which has engaged the attention of many 
physicians of ample experience, and in reference to which there is still a dif- 
ference of opinion among the highest authorities in medicine. I refer to 
scarification of the gums. 

The gum-lancet is much less frequently employed than formerly. It is 
used more by the ignorant practitioner, who is deficient in the ability to 
diagnosticate obscure diseases, than by one of intelligence, who can discern 
more clearly the true pathological state. Its use is more frequent in some 
countries, as England, under the teaching of great names, than in others, 
as France, where the highest authorities, as Rilliet and Barthez, dis- 
countenance it. 

It is well to bear in mind, as aiding in the elucidation of this subject, the 
remark made by Trousseau, that the tooth is not released by lancing the gum 
over the advancing crown. The gum is not rendered tense by pressure of 
the tooth, as many seem to think, for if so the incision would not remain 
linear, and the edges of the wound would not unite, as they ordinarily do 
by first intention within a day or two. This speedy healing of the incision 
unless the tooth be on the point of protruding is an important fact, for it 
shows that the effect of the scarification can last only one or two days. The 
early repair of the dental follicle is probably conservative, so far as the 
development of the tooth is concerned. It may help us to understand how 
active, how powerful, the process of absorption is, if we reflect that the roots 
of the deciduous teeth are more or less absorbed by the advancing second 
set, without much pain or suffering from the pressure. If the calcareous 
particles of the teeth are so readily absorbed, what is the foundation for the 
belief that the fleshy substance of the gum is absorbed with such difficulty ? 
Too much importance has evidently been attached to the supposed tension 
and resistance of the gum in the process of dentition. 



DENTITION. 695 

Follicles in the period of development are especially liable to inflamma- 
tion. We see this in the follicular stomatitis and enteritis so common when 
the buccal and intestinal follicles are in a state of most rapid growth. Does 
not this law in reference to the follicles hold true of those by which the teeth 
are formed, so that the period of their enlargement and greatest activity, 
which corresponds with the growth and protrusion of the teeth, is also the 
period when they are most liable to congestion and inflammation ? It seems 
probable that the dental follicles are most liable to become inflamed, and 
therefore tender, from various causes apart from dentition at the time of their 
greatest functional activity. 

If there be no symptoms except such as occur directly from the swelling 
and congestion of the gum, the lancet should seldom be used. The patho- 
logical state of the gum which would, without doubt, require its use is an 
abscess over the tooth. As to the symptoms which are general or referable 
to other organs, as fever and diarrhoea, the lancet should not be used, because 
the symptoms can be controlled by other safe measures. All co-operating 
causes should first be removed, when in a large proportion of cases the 
patient will experience such relief that scarification can be deferred. 

If the state of the infant be one of immediate danger, as in eclampsia, 
and it be not quickly relieved by the ordinary remedies, scarification may 
not only be proper, but required to ensure safety. For in such cases all 
measures, provided that they are safe and simple, which can possibly give 
relief, should be employed without delay. But I can recall to mind only three 
accidents of dentition which would be likely to be benefited by scarification — 
namel} T , suppurative inflammation in the dental follicle, extreme fretfulness 
continuing day after day, and convulsions. But since the bromide of potas- 
sium and hydrate of chloral have come into use as nervous sedatives and as 
efficient remedies for clonic convulsions, scarification of the gums is much less 
frequently required, for even severe eclampsia commonly yields to these medi- 
cines if the condition of the bowels be attended to. In some instances I 
have found that the elixir anisi (aniseed cordial) of the National Formulary, 
containing as it does anethol and the oils of fennel and bitter almond, 
administered in doses of ten drops to an infant of one year, is apparently 
more quieting in cases of restlessness than the bromide. It may be given 
with the bromide. 

Second Dentition. — Rilliet and Barthez mention particularly neuralgic 
pains, rebellious cough, and diarrhoea as effects which they have observed of 
the second dentition. Rilliet relates the case of a girl eleven years old who 
had a very obstinate and protracted cough, the paroxysms lasting often half 
an hour to one hour. This cough immediately and permanently disappeared 
when the molars pierced the gums. 

Dr. James Jackson x says : u I have seen persons between twenty and thirty 
years of age much affected by a wisdom tooth not yet protruded, and distinctly 
relieved by cutting the gum. But I think the most common period of suffering 
from the second dentition is from the tenth to the thirteenth year. The most 
characteristic affections are wasting of flesh and nervous diseases. The boy loses 
his comeliness and his complexion is less clear, while emaciation takes place 
in every part, though mostly perhaps in the face. The nervous symptoms are 
various, but the most common are a change in the temper and a loss of spirits. 
With these there is some loss of strength. The patient is unwilling to engage 
in play, and soon becomes tired when he does so. Among the distinct symp- 
toms which are not uncommon I may mention pain in the head and in the 
eyes. The headache is not commonly severe, but it is such as inclines the patient 
to keep still. The eyes are not only painful, but are often affected with the 
morbid sensibility to which these organs are subject. I have known boys truly 

1 Letters to a Young PJu/sician. 



696 



LOCAL DISEASES. 



anxious to pursue their studies, obliged to give them up on this account ; and these, 
not having the disposition to play, will of choice pass the day with their mothers 
and increase their troubles for the want of air and exercise. Nervous affections 
of a more severe character are sometimes manifested. 7 ' 

Whether the symptoms which have been attributed to second dentition 
have always been due to this cause is questionable. Practically, however, it 
matters little whether we recognize dentition as the cause or assign some- 
thing else. Hygienic and medicinal measures to improve the general health 
will usually suffice to relieve the patient. Elsewhere I have related the case 
of a boy of nervous temperament, about seven years old, who recovered 
immediately from a cough which had lasted for several weeks by taking a 
mixture of iron and nitric acid. Many do well without medicine, simply by 
hygienic measures. Dr. Jackson says : " The remedies which I have found 
most useful are as follows : First, a relief from study or from regular tasks, 
yet using books so far as they afford agreeable occupation or amusement. 
Second, exercise in the open air, preferring the mode most agreeable to the 
patient, and in more grave cases the removal from town to country." 

Ranula. 

Ranula is a cyst beneath the tongue, usually intimately related to the 
salivary ducts. The ducts becoming closed, the epidermic lining is deposited 
in the interior, and the secretion accumulates until a large tumor is formed 
which presses the tongue upward and backward, greatly interfering with 
the functions of that organ. These cysts are readily recognized on inspec- 
tion of the under surface of the tongue. The treatment may at first be the 
passing of a seton (Fig. 197) to secure drainage of the sac and adhesion of 



Fig. 19- 




Ranula : introduction of seton. 



its walls. If this fail, resort to free incision, and keep the wound open ; 
or excision of a portion of the walls may be necessary. If the disease per- 
sists, open the cyst and cauterize with nitrate of silver, or even nitric acid. 
If the cyst project in the neck, open it in the middle line below the hyoid 
bone, and keep it open till the cavity is obliterated. 



DENTITION. 



697 



Fig 



Alveola. 

Hypertrophy of the alveola appears as a congenital affection, and con- 
sists of an expanded and prolonged development of the alveolar borders of 
the maxillae, immense thickening of the fibrous tissue of the gum, and exu- 
berant growth of the papillary surface. When fully developed the patient 
presents an extraordinary appearance — a large 
mass, dense, inelastic, insensitive, pink, and 
smooth, protrudes from the mouth (Fig. 198). 
Excision should be performed. 

Vascular growths, nsevi, and aneurysms 
by anastomosis form in the tissues about the 
necks of the teeth, especially between the 
incisors or canines and lateral incisors of the 
upper jaw ; they have a purplish color ; are 
smooth and streaked, with many vessels; are 
easily compressed and become pale and re- 
duced, but are elastic and resume their pre- 
vious aspect on removal of pressure. The whole gum is red, turgid, and 
swollen, and the little tongues of gum between the necks of the teeth are 
enlarged and spongy ; troublesome hemorrhage occurs later in the disease. 
These growths are now more readily destroyed by the galvano-cautery needles. 
If this treatment fail, excision should be performed with a scalpel, the bleed- 
ing being controlled by pressure and ice. 

Dentigerous cysts are collections of serum in the maxillary bones depend- 
ent upon impacted misplaced teeth ; they arise only when the tooth or teeth 
associated with them are imbedded in the substance of the jaw-bone, and do 
not occur after the tooth has pierced the gum ; they occur in connection 




Front view of tumor of alveolus, 
due to hypertrophy and dilatation 
of tooth-fang (Bryant). 



Fig. 199. 



Fig. 200. 





Dentigerous tumor of jaw (Bryant). 

with the permanent teeth, which may fail to 
pierce the gum, either from the great depth 
of the sac or growth in an oblique direction, 
or from arrest of development. The symp- 
toms are expansion of the jaw-bone, weight, 
and tension, and disfigurement of the fea- 
tures (Fig. 199). The diagnosis depends on 
pressure, which reveals fluid, expansion of 
bone, and crepitation like stiff parchment, 
and absence of a tooth or of teeth which have never appeared. The treatment 
consists in opening the cyst freely with knife, gouge, or trephine, extraction 
of the imbedded tooth, and, if the expansion is large, removal of the dilated 
bone (Fig. 200). The result is always satisfactory. 



Canine tooth as seen in a ease of den- 
tigerous cyst. Expanded lower jaw 
with tooth : b, natural size ; a, bone 
removed by the trephine (Bryant). 



698 LOCAL DISEASES. 

Tonsil. 

Abscess of the tonsil is a frequent result of acute inflammation. It 
should be punctured as soon as pus is detected, care being taken to avoid 
wounding the internal carotid artery. 

Select a broad spatula and a sharp-pointed straight bistoury, wrapped to within 
about half an inch of its extremity ; place the patient in a chair in front of a good 
light, the head firmly supported by an assistant ; lay the spatula slightly on the 
tongue until the abscess is brought into view ; pass the knife backward, avoiding 
wounding the tongue, and incline the point, when it penetrates the tonsil, toward 
the median line of the fauces, thus protecting the internal carotid from all danger ; 
if the abscess cannot be sufficiently exposed, it may be necessary to direct the point 
of the knife by the index finger of the left hand ; if the abscess contain a large 
amount of pus, the patient's head should be thrown forward immediately after the 
puncture to avoid the flow into the pharynx or larynx. 

Chronic inflammation of the tonsil is caused by repeated acute conges- 
tions of the pharyngeal mucous membrane, and consists of an equable and 
uniform overgrowth of all the histological elements of the follicles ; the size 
and shape of the entire tonsil undergo an alteration. It forms a globular 
and often pedunculated tumor which may project so far as to interfere with 
breathing ; or. it may grow vertically, extending below into the pharynx and 
upward toward the posterior nares. 

The symptoms depend upon the peculiarties of the hypertrophy. When 
large and protruding it interferes with natural sleep, affects the voice, and 
often the general health is impaired. There is " a vacuous, heavy look from 
obstruction to breathing and consequent imperfect aeration of the blood ; also 
imperfect development, and often stunting of the growth ; the mouth is kept 
open, the breathing is stertorous, and during sleep snoring ; there is usually 
chronic nasal, and often aural, catarrh, from the extension of irritation from 
the tonsils to the neighboring mucous surfaces ; the speech is nasal and indis- 
tinct or dead ; the chest is often ill-developed, pigeon-breasted, or has the 
diaphragmatic constriction." l 

The treatment should be the application of iodine in the early stages. In 
advanced cases the only proper treatment is removal. Various methods 

Fig. 201. 




have been employed to destroy the tonsil — compression, massage, electrol- 
ysis, galvano-cautery puncture, ignipuncture, and the snare. But excision 
with the tonsillotome has proved the most useful, especially when the tonsil 
projects. The danger from hemorrhage is comparatively slight ; the opera- 

1 Ashby and Wright, Diseases of Children, p. 54. 



DENTITION. 699 

tion is quickly performed and does not require a specially skilled hand. The 
Mackenzie instrument is the more simple (Fig. 201). 

An anaesthetic should be given to the child to the extent of slight 
narcosis, but not so as to abolish the reflexes. The patient is placed on the 
back, the mouth-gag is introduced, and the tonsils removed. The child is 
then turned on its face to facilitate the flow of blood from the mouth. 
Knight states that there should be no hesitation in adopting this method in 
children under ten years of age and in older children of nervous tempera- 
ment. He advises to remove as much of the tonsil as possible, for the stump 
does not shrink and may prove a source of irritation, and the farther out the 
section is made the more nearly we approach healthy tissue. 

In the absence of a tonsillotome the tonsils may be partially removed with 
curved hook-teeth forceps, and a straight probe-pointed or curved scissors. If the 
patient is a child, give chloroform, and when sufficiently under its influence to 
open the mouth, seize the tonsil, draw it out from between the pillars, and, having 
the knife-blade wrapped to within an inch of the point, cut away from below upward 
the proper amount. 

Recurrent tonsillitis is a term used by Leland 1 of Boston in describing 
that form of tonsillitis which recurs with such violent symptoms, often with- 
out an\ T premonition. He says: "The onset of the exacerbation maybe 
sudden, ushered in by a chill more or less marked, with high fever, followed 
by more or less formidable swelling, with exudation, white or yellow patches, 
etc., to subside after a week or two ; or it may go on to abscess, intratonsillar 
or peritonsillar, with great distress, forced starvation, restless days, sleepless 
nights, extreme prostration and anxiety (both for patient and physician), 
requiring weeks or months for recovery. The mental state of the attendant 
is not an enviable one when he knows that he may have a sudden fatal ter- 
mination from extreme faucial swelling, oedema glottidis, suffocation from 
sudden discharge of pus or by involvement of the great vessels — the carotid 
and internal jugular — by extension of inflammation." 

He describes two varieties of tonsils which are subject to such recurrence : 
First is the tonsil which in an inflammatory attack simply rounds out an 
increase in size — smooth, red, shiny, the parenchymatous variety. The crypts 
or lacunae are not markedly developed, but the lymphoid elements are increased 
in size and in number. If the capsule is broken and the finger introduced, a 
soft, friable feeling is communicated to it, something like that of the normal 
spleen. After several inflammatory attacks these tonsils are adherent to the 
pillars of the fauces, and especially when this adhesion has taken place are 
they apt to be permanently enlarged, and even to close the faucial passage, 
pushing forward the uvula, with every slight cold or disturbance of the 
digestion, or from some other ill-defined cause, so that the voice and 
respiration of the sufferer are much affected. 

The other variety is the chronic tonsil, which has a hard, rubbery feel, 
whose surface is full of crypts or lacunas which run into its depth from one- 
quarter of an inch to one inch or more, which crypts usually contain inspis- 
sated secretion of a cheesy consistency and of a most offensive odor. This is 
the ' lacunal' tonsillitis of Wagner or Brown. It may be large enough to just 
project beyond the pillars or it may reach even to the uvula. Because of the 
diseased condition of the interior of the crypts it is especiall} T liable to fre- 
quent inflammatory attacks from even the slightest cause. It acts as a foreign 
body in the fauces, producing a tickling, hacking cough, giving a malodorous 
breath, and doubtless keeps the general health of the patient down from the 
absorption of these decomposing cheesy masses through the tonsil itself or 

1 Boston Med. and Surg. Joum., Oct. 12 and 19, 1893. 



700 



LOCAL DISEASES. 



from their being swallowed. It is said that attacks of indigestion light up 
inflammatory conditions in the tonsil. It is probably also true that the con- 
tents of the crypts excite or keep up fermentative indigestion. This variety 
of tonsil is doubtless the result of repeated attacks of the first variety. 

The treatment recommended by Leland is the removal of the inspissated 
secretion of the crypts on which the inflammation depends, and " the tearing 
away of the partitions between the crypts so as to connect the many small 
contracted mouths into a few large wide-open ones.' 1 For this purpose he has 
devised a knife (Fig. 202), which he uses as follows : 

The olive-shaped tip of the knife is introduced into a crypt in the upper part 
of the tonsil, and then turned downward and inward and made to come out by 
another in the lower part. The substance of the organ between 
these two holes is then cut through. This can be repeated 
from three to ten times at a sitting until the surface of the 
tonsil presents the appearance of being full of slits. There 



Fig. 202. 




duced oftentimes to its fullest extent without danger. As 
soon as the bleeding has ceased the slits are painted with 
Monsel's solution or with a mixture of glycerin and tincture 
of iodine in equal parts. These solutions may be put upon 
the end of the cotton-wrapped bent applicator and crowded 
down to the bottom of the tonsil. This is done for antisepsis 
and to prevent the wounds from uniting immediately, as they 
tend to do, thus rendering the operation futile. The patient is 
advised to gargle with hot water very frequently for three or 
four days, and to return in a week for another operation, if 
necessary. Dobell's or Seller's solution or a little borax may 
be added to the hot water. It usually requires from four to 
eight sittings to cause a large tonsil to recede from the median 
line to a position almost out of sight behind the pillars of the 
fauces. If the tonsil is very fibrous and hard, there will be 
left small projections upon the surface. These can be readily 
nipped off with adenoidal forceps or can be seized by long 
dressing forceps and removed with a blunt-pointed bistoury. 
The patient is then instructed to return on the slightest symp- 
tom of the old trouble, that any crypt which has escaped treat- 
ment may be attended to. In adults this method can be carried 
out with the greatest facility and ease, and often in children as 
young as ten years of age. I have also been able to operate 
with satisfaction, although with a little more necessary per- 
suasion, in children as young as five or six ; and recurrent 
tonsillitis is not apt to occur younger than that, at least in my 
experience. The first variety of tonsillitis, in which the crypts 
are not so much developed or so fully diseased, is much 
benefited by this method if the capsule is torn or cut and 
the solution applied to its interior, and perhaps even if only adhesions between the 
tonsil and the pillars of the fauces are cut away by this method. 

Adenoid vegetations consist of nodules of lymphoid tissue which form 
masses of soft tissue or ridges or lobules on the upper and lateral surfaces 
of the posterior nares. They often exist in connection with hypertrophy of 
the tonsils, and they have been called the pharyngeal tonsil. They may be 
seen with the laryngeal mirror, and may be felt with the index finger, well 
protected by a shield of celluloid, passed behind the soft palate. They may 
be suspected to exist in a child who snores, has a mucous discharge from the 
nose, and a thick speech. 

According to Power, 1 the facial expression is characteristic in the later stages ; 
there is a dull and heavy look, a sallow complexion, thick and prominent lips ; 

1 Power, Surg. Dis. Children, p. 281. 



CATARRHAL PHARYNGITIS, ETC. 701 

mouth open: nostrils narrow; alas indented at junction of superior and inferior 
lateral cartilages ; bridge of nose broad and often crossed by a large vein ; eyes 
appear unduly far apart ; often dulness of hearing. 

The treatment is removal. Various instruments have been devised for 
this purpose, as curettes, forceps, and artificial nails, but a Volkmann's 
spoon, passed through the anterior nares, guided by a finger in the pharynx, 
effects the purpose. The child should be brought partially under the anaes- 
thetic and a gag employed. 

Power has the head of the patient hang over the table, so as to prevent the 
escape of blood into the air-passages. 

The nasal cavity should be swabbed out during the operation with 
absorbent cotton. On removing the gag the bleeding ceases. Recovery 
is usually rapid. 



CHAPTER IV. 

CATAEEHAL PHARYNGITIS, PEBIPHAEYNGEAL ABSCESS, 
OESOPHAGITIS. 

Catarrhal Pharyngitis. 

Children of all ages are liable to inflammation of the pharynx. In its 
mildest form it often, doubtless, escapes detection in the young infant. In 
older patients it is revealed by pain in swallowing solid food and more or less 
tumefaction below the ears, apparent to the sight. It is said to be less fre- 
quent in infancy than in childhood. In the adult and in children over the 
age of four or five years inflammation of the pharyngeal surface is often con- 
fined to the portion of membrane which covers or immediately surrounds the 
tonsils. It occurs in connection with inflammation of these glands. But in 
infancy and early childhood this limitation is comparatively rare. Catarrhal 
inflammation of the fauces at this age is ordinarily general, the tonsils par- 
ticipating in the morbid state. 

Pharyngitis is primary or secondary. The secondary form occurs in mea- 
sles, scarlet fever, bronchitis, croup, pneumonia, and occasionally in other 
affections. As these diseases are common, physicians are oftener called to 
treat patients who have the secondary form than the primary. Rilliet and 
Barthez met 83 secondary to 16 primary cases. 

Anatomical Characters. — The pathological anatomy of pharyngitis is 
ascertained by depressing the tongue and inspecting the fauces. The faucial 
surface is seen to be redder than in health, with more or less swelling accord- 
ing to the intensity of the inflammation. In the primary inflammation the 
color is commonly bright red, almost like that of arterial blood. If, on the 
other hand, the inflammation occur in connection with a constitutional malady, 
the hue is often darker. In grave cases of scarlet fever or measles it is some- 
times even livid, indicating a vitiated state of the blood — a condition of real 
danger. The tonsils are tumefied so as to project, though not to the extent 
which we observe in the adult. They are less firm than in the normal 
state. The follicles of the throat are enlarged and active, pouring out a 
muco-purulent secretion. This is sometimes seen in a layer over the tonsil 
or the posterior portion of the fauces. In a case of primary pharyngitis 



702 LOCAL DISEASES. 

examined after death by Rilliet and Barthez the tonsils were softened, infil- 
trated with pus, and slightly enlarged. A layer of bloody mucus lay on the 
pharyngeal surface, which was dark red and thickened. The submaxillary 
glands were also swollen and somewhat softened. 

If the inflammation be intense, the deep-seated portions of the tonsils 
become involved, and even sometimes the adjacent connective tissue. In such 
cases by applying the fingers in the hollows below the ears the tonsils can be 
felt. 

Causes. — The usual cause of primary pharyngitis is exposure to cold. 
It also occasionally occurs from the use of drinks too hot or containing some 
irritating substance. I have met it in the most intense form caused by swal- 
lowing boiling water, and in one case from acetic acid taken through mis- 
take. When it occurs in the eruptive fevers it is usually part of a more 
extensive phlegmasia, in which the buccal and perhaps laryngeal and nasal 
surfaces participate. 

Symptoms. — Fever, with thirst and loss of appetite, is common, and is 
usually proportionate in intensity to the extent and severity of the inflamma- 
tion. At first there is dryness of the faucial surface, and this is succeeded 
by a more or less abundant viscid secretion. Swallowing is painful, except 
in mild cases. The muscles of the anterior half-arches, which by their con- 
traction close the opening from the pharyngeal to the buccal cavity, and those 
of the posterior arches, which close the opening to the nasal cavity, both 
which sets lie a little under the mucous membrane, are often so infiltrated 
with serum that their contractile power is diminished, and if the same happen 
with the constrictor muscles, which carry downward the food, swallowing 
becomes difficult, and in the attempt more or less of the ingesta is liable to 
return into the mouth or enter the nostril. During health the air passes 
through the nostrils in the pronunciation of two letters only — namely, n and 
m — but in severe pharyngitis, in consequence of the swelling and the impair- 
ment of the action of the muscles concerned in speech, the air passes through 
the nostrils with the utterance of many words, producing the nasal tone of 
voice. Sometimes the inflammation traverses the Eustachian tube to the 
middle ear, causing earache, which may be relieved by the escape of pus down 
the tube or by perforation of the drum into the external ear. 

The breath is foul, but not fetid ; the respiration normal or but slightly 
accelerated ; there is commonly no cough, but it is sometimes present, due to 
the extension of the inflammation to the upper part of the larynx or to the 
collection of mucus around the aperture of the glottis. In most cases of 
pharyngitis a light fur covers the tongue, and stomatitis of a mild grade 
is present, as shown by redness of the buccal surface and increased mucous 
secretion. 

Chronic pharyngitis, which is so common in adults, and which is produced 
in some by gastric derangements, and in others by excessive smoking or the 
prolonged use of intoxicating drinks, and in others still by the syphilitic or 
mercurial cachexia, is comparatively rare in children. 

Prognosis. — In mild cases of pharyngitis convalescence commences 
within a week. If the inflammation be dependent on a constitutional malady, 
it may continue considerably longer, especially if the glands of the neck and 
the connective tissue be much involved. The prognosis in secondary pharyn- 
gitis is less favorable than in that of the primary form. In fatal cases there 
is usually a vitiated state of the blood, either from the coexisting constitu- 
tional disease or from previous cachexia. 

Pharyngitis may, however, become dangerous from complications to which 
it gives rise. The proximity of the inflammation to the brain or its effect 
upon the cerebro-spinal axis through the medium of the nerves sometimes 



CATARRHAL PHARYNGITIS, ETC. 703 

oives rise to clonic convulsions. In a recent case of primary pharyngitis in 
iny practice repeated and violent convulsions occurred in an infant about one 
year old from this cause. They commenced at the inception of the inflamma- 
tion, and constituted the only real danger. Pharyngitis may interfere mate- 
rially with nutrition in consequence of the dysphagia, but in most cases of 
primary pharyngitis this symptom does not continue sufficiently long to 
endanger the life of the patient. In grave constitutional affections, as scarlet 
fever, the difficulty of swallowing and the consequent innutrition augment 
the danger. As regards, therefore, the prognosis in catarrhal pharyngitis, 
whether primary or secondary, it may be stated as a rule that it is not, per se, 
a fatal disease, but is only so from complications or from aggravating the 
primary malady with which it is associated. 

Diagnosis. — This is not difficult, provided that attention be directed to 
the throat ; but the physician often fails to discover it at his first visit from 
neglecting to examine this part. In many cases the local symptoms are not 
well-marked, and in the absence of these the febrile reaction may at first be 
referred to some other cause than the true one. Inspection not only reveals 
the presence of inflammation, but enables us to determine the form with the 
aid of the microscope. This instrument, now in common use, enables us to 
differentiate simple catarrhal inflammation from diphtheritic, pseudo-diph- 
theritic, and other forms of pharyngitis. 

Treatment. — Mild cases of simple pharyngitis require little treatment. 
With moderate counter-irritation around the neck, as by one of the following 
prescriptions, and by appropriate remedies the patient recovers : 



R. Olei caryophylli, ^ij ; 

Olei camphorati, £iv. — Misce. 



For external use. 

R . Olei terebinthinse, ,^ss ; 

Olei camphorati, t ^iij. — Misce. 

For external use. 

Sometimes warm-water applications, or, if the temperature exceeds 103° 
F., applications containing ice. give most relief. 

In severe forms of the disease occurring independently of any other 
malady more active measures are sometimes required. Carl Seller's tablet, 
which, according to the published formula, contains several sodium combina- 
tions with aromatics and antiseptics, will be found very useful for this and 
other forms of pharyngitis, sprayed frequently over the fauces according to 
the following formula : 

R. Creasoti (Morson's beechwood), gtt. ij ; 
Seiler' s tablet for the fauces, No. j ; 

Aquae destillat., J;iij. — Misce. 

Spray fauces, and if necessary nares, every hour. 

If there be stupor or restlessness, with unusual heat of head, and start- 
ing or twitching of the limbs which threatens convulsions, two to five grains 
of the bromide of potassium given every two or three hours produce a calm- 
ative effect. 

Diaphoretic and sometimes cardiac sedatives are also indicated, such as 
liquor ammonias acetatis, spiritus setheris nitrosi, ipecacuanha, and aconite. 
Medicines of this kind may be variously combined according to the age and 
condition of the patient and the severity of the disease. 

As the symptoms abate the intervals between the doses may be in- 
creased. 



704 LOCAL DISEASES. 

In cases attended by much tenderness and dysphagia great relief is often 
obtained by hot poultices frequently applied over the neck. 

The treatment of secondary pharyngitis will be described in connection 
with the treatment of the diseases which it complicates. Suffice it here to 
say that this form of inflammation must not be treated by those depressing 
remedies which may be useful in cases of idiopathic pharyngitis. 

Peripharyngeal Abscess. 

An abscess occasionally forms between the pharynx and vertebral column 
(retropharyngeal) or upon the side of the pharynx in the submucous connec- 
tive tissue. This constitutes a disease which may be fatal, but which can 
ordinarily be promptly relieved by the surgeon. 

Yet if we look over the records of peripharyngeal abscess we shall see 
that in a large proportion of fatal cases the disease was supposed to be some- 
thing else, and so treated until its nature was revealed by post-mortem exam- 
ination. 

This abscess may occur at any age, but is most common in infancy and 
childhood. It is more frequent in the first two years of life than at any 
other period. Of the cases collated by Allen in which the age is stated, 20 
were under ten years and 21 over this age. The abscess occurs in some 
patients from caries of the vertebral column, and in others from inflamma- 
tion developed in the connective or small lymphatic glands lying immediately 
outside the pharynx, or from a catarrhal pharyngitis. The patient is usually 
scrofulous or in a reduced state of system. 

Writers describe two kinds of peripharyngeal abscess, the primary and 
secondary. This distinction is based on the fact whether or not the inflam- 
mation which leads to the abscess be dependent on an antecedent pathological 
state. In the primary form the cause is usually some irritating substance 
which has been swallowed, and which, lodging in the pharynx, produces 
phlegmonous pharyngitis. 

The cause is mentioned in 20 cases of the primary form, collated by 
Allen, as follows : exposure to cold, 10 cases ; lodgement of bone in pharynx, 
8 cases ; blow with a fencing-foil, 1 case. In the last case the button of a 
fencing-foil passed through the right nostril into the pharynx. 

The secondary form occasionally occurs after measles and scarlet fever. 
The inflammation of the pharynx common in those diseases extends to the 
subjacent connective tissue, and, aided by the dyscrasia of the patient, 
becomes suppurative. The most common cause of the second form is, 
however, caries occurring in the cervical vertebrae, and it is similar, both 
as regards cause and nature, to lumbar abscess. It would follow the same 
chronic course were it not for its proximity to the air-passages, which renders 
the symptoms urgent and dangerous. In a few recorded cases the abscess 
was a sequel of erysipelas. 

In 19 cases of secondary abscess in Allen's collection the cause is assigned as 
follows : erysipelas of face, 2 ; inflammation following a fall upon the inferior 
maxilla, 1 ; after cerebritis, 1 ; syphilis, 4 ; caries of the cervical vertebras, 6 ; 
scrofula, 5. 

The opinion is expressed by Mr. Fleming l that the suppuration of peri- 
pharyngeal abscesses begins in a large proportion of cases in the small 
lymphatic glands which lie in the connective tissue external to the pharynx. 
The late Prof. George T. Elliott 2 has recorded the case of an infant of seven 
months in whom abscess immediately followed and was apparently due to 
parotiditis. 

1 Lublin Journ. of Med. Sci., vol. xviii. 2 Obst. Clinic, X. Y. 



CATARRHAL PHARYNGITIS, ETC. 705 

In rare instances, the abscess, or the local disease which leads to it, appears 
to exist from birth. Thus Dr. E. 0. Hocken relates 1 the history of an infant 
which died at the age of nine weeks. It had always, when taking the breast, 
thrown back its head as if nearly suffocated. The walls of the abscess were 
thick and firm, described by the writer as cartilaginous. Occasionally there 
is no apparent cause of the abscess except the strumous or cachectic state. 

Anatomical Characters. — The seat of the abscess is not the same in 
all cases. The swelling can ordinarily be seen on examining the fauces, but 
occasionally it is so low as to be really periesophageal, and therefore invisible. 
The size of the abscess varies : sometimes it is large, pressing inward the 
wall of the pharynx even against the velum palati, and into the posterior 
nares if the abscess have a high location, or if lower against the larynx, so 
as to embarrass respiration. Sometimes the abscess is so large or has such 
lateral extension that there is external swelling along the side of the neck. 
In a few cases on record the pus, instead of being discharged into the pharynx, 
made its way down the neck between the muscles and the connective tissue 
to the pleural cavity, which it entered, producing fatal pleuritis. 

The walls of the abscess have been found in a different state in different 
cases. Sometimes the sac at the projecting point is so thin that it seems as 
if there might have been a spontaneous cure could life have been preserved 
a few hours longer. In other cases the sac is so thick and firm that its rup- 
ture for many days would be impossible, 

Symptoms. — The precursory symptoms differ in different cases according 
to the nature of the cause, whether it be phlegmonous pharyngitis or simply 
adenitis or vertebral caries. If the abscess proceed from caries, it is preceded 
by deep-seated pain, greatly increased by movements of the head, and prob- 
ably preceded also by induration along the sides of the vertebrae. 

The patient with this disease is restless, his mouth hot and dry, tongue 
furred, deglutition more or less difficult. Sometimes after suppuration has 
occurred there are alternations of rigors and fever. The symptoms indicate 
approximately the seat of the inflammation, but on examination we do not 
find that degree of redness of the mucous surface which we had been led to 
expect. The tissues which are chiefly involved in the inflammation, being 
submucous, are hidden from view. We observe redness of the pharynx, but 
it is disproportionate to the intensity of the symptoms. Some patients fre- 
quently experience a chilly sensation through the entire period of the abscess, 
though greater at one time than at another, and occasionally convulsions 
occur, especially in young infants. In ordinary cases embarrassment of res- 
piration begins early, and is the cause of the chief danger. It becomes more 
and more marked as the abscess increases. It is noticed both during inspi- 
ration and expiration. The dysphagia also increases, sometimes to such a 
degree that drinks are taken with difficulty and solid foods refused. The 
respiratory symptoms bear considerable resemblance to those in protracted 
laryngitis, for which this disease has been mistaken. While the respiration 
becomes impeded or whistling, the voice is also feeble or indistinct from the 
pressure of the tumor. 

But the symptoms described above are not all present in every ease. 
They vary according to the size and location of the abscess, whether it be 
high or low, posterior or lateral. I have met the disease in a child old enough 
to make known the subjective symptoms, in whom there was little or no dys- 
phagia ; and others report similar cases. When the tumor has attained such 
a size that it produces well-marked symptoms and jeopardizes the life of the 
patient, it or a part of it can ordinarily be seen on depressing the tongue. 
but usually its location and condition can be better ascertained by exploration 
1 Prov. Med. and Surg. Joum., 1842. 
45 



706 LOCAL DISEASES. 

with the finger. The dyspnoea increases as the abscess enlarges, and after a 
time, unless it burst spontaneously or be opened by the surgeon, imperfect 
oxygenation of the blood results. In some patients paroxysms of dyspnoea 
occur, so as to threaten immediate suffocation ; coughing or attempts to swal- 
low induce these paroxysms, and the patient is forced to remain in an erect 
or semi-erect posture ; the tongue is protruded, the head thrown back, the 
pulse is frequent and rapid, the limbs become livid and cool, and finally death 
results from dyspnoea. Occasionally, when death seems inevitable, the abscess 
breaks during the struggles of the child and the patient is restored to health. 
In rare cases the result is different. The trachea and bronchial tubes are 
deluged by the purulent discharge and immediate suffocation occurs. 

The following was an example : In May, 1871, a boy two years and five months 
old, who had the symptoms of an abscess for three months, was brought to the class 
at Bellevue. The head was carried on one side, its rotation caused pain, and a 
laryngeal rale accompanied respiration. The upper part of the tumor could be 
detected by the finger, but on account of its low location it was impossible to open 
it with a bistoury. The temperature was 103°, pulse 156. The case remained 
under observation, but in a few days the dyspnoea suddenly became so urgent that 
death was imminent, when the attending physician of the class, Dr. Swezey, broke 
the abscess with his finger and pus was ejected on the floor; death, however, 
occurred almost immediately. 

A correct appreciation of the symptoms and nature of peripharyngeal abscess 
will be best obtained by relating a case. I select the following from the Trans, of 
the Lond. Pathol. Soc, Oct. 20, 1846: A female infant died at the age of seven 
months, having had difficult breathing three weeks and extreme dyspnoea during 
the last days of life. The dyspnoea was constant, and was aggravated by mental 
excitement, by movements of the body, and by exposure to cold. During the par- 
oxysms a peculiar croupy sound accompanied inspiration. There was no dysphagia 
through the entire sickness, and death occurred from apnoea. The sac of the abscess 
was of the size of a pigeon's egg, and was situated between the upper cervical ver- 
tebrae and the back of the pharynx. The abscess was flattened in front, so as not 
to cause any decided prominence of the wall of the pharynx. From the sac a sec- 
ond small cyst extended forward, forming a nipple-like swelling in the pharynx 
which completely closed the orifice of the glottis. Its aperture of communication 
with the body of the abscess admitted the point of the little finger, and the whole 
swelling was freely movable and perfectly translucent at its extremities and sides. 
The abscess might have been easily punctured, with probably the preservation of 
life. 

The duration of this malady is very different, according to the inflam- 
mation, the rapidity with which the abscess enlarges, and the direction which 
it points. A lateral or downward extension is not so immediately dangerous 
to life as the anterior. 

The time when the abscess begins to form cannot be precisely ascertained, 
and most writers in determining its duration compute from the first appear- 
ance of symptoms which are referable to the pharynx. 

Dr. J. Byrne l relates a fatal case in which the disease had apparently continued 
only about one week. The patient was an infant one year old, and its death was 
from apnoea. The abscess was large, extending from the base of the skull to the 
thorax and pressing both on the larynx and trachea. M. Besserer 2 gives the his- 
tory of an infant four months old who died in the same way after thirteen days. 
An infant nine months old, whose case was published by Dr. W. C. Worthington, 3 
lived nine days. The abscess occurred from exposure to cold ; the patient was 
treated for croup and died from suffocation. The anterior wall of the abscess was 
very thin. In two cases treated by me the symptoms indicated a continuance of 
the disease from two to four weeks, and in a third case four months. A fourth case 
is interesting on account of the short duration of the severe symptoms. The fol- 

1 Amer. Journ. of Med. Sci., 1838. 2 Arch. gen. de Med., 1840. 

3 Prov. Med. and Surg. Journ. , 1842. 



CATARRHAL PHARYNGITIS, ETC. 707 

lowing is the record of it: M. E , aged seven months, female, nursing, inmate 

of the^ New York Foundling Asylum, was observed to have difficult breathing for 
the first time on March 28, 1875. Since about March 8th some swelling had been 
noticed along the side of the neck, but it gave rise to no marked symptoms, and she 
had not seemed ill till the obstruction in the respiration commenced. At my visit 
on the evening of the 28th the infant was pointed out to me as in a dying condition. 
She was lying in a state of stupor, pallid and gasping for breath, with a tempera- 
ture of 10*3°. and very feeble pulse, numbering about 200 per minute. On carrying 
the linger into the throat an abscess could be readily detected situated in the walls 
of the pharynx, on the left side posteriorly. This was easily opened by a curved 
bistoury, around which adhesive plaster was wound to within half an inch of the 
point. The breathing immediately began to improve. On the following day the 
infant was playing in the mother's lap, with a pulse of 140, but a normal tempera- 
ture. With the use of cod-liver oil and the syrup of the iodide of iron its health 
was soon fully restored. In the fifth case the abscess was ruptured by the finger, 
and in a sixth it was opened by the lancet. All these patients recovered. 

"When the abscess grows slowly and presses lightly on the air-passages the case 
may continue for months. Such a one was observed by the late Professor Willard 
Parker (Allin). This infant was one year old ; it suffered from pharyngeal symp- 
toms nine months, was treated for tonsillitis, and death occurred as usual from 
apncea. The abscess was two inches long, and there was no disease of the vertebrae. 
The same surgeon saved the life of another patient four years old, in whom the 
disease was protracted, by puncturing the abscess ; the late Professor Post also 
treated successfully a case which had continued three months (Allin). 

Diagnosis. — The diagnosis of retropharyngeal abscess is ordinarily easy, 
provided that the physician examine carefully and bear in mind the occasional 
occurrence of such an abscess. In a large proportion, however, of the 
recorded fatal cases the true nature of the disease was not recognized during 
life. Especially is the diagnosis difficult when the cerebro-spinal system is 
early implicated and symptoms arise which divert attention from the throat 
to the brain. 

The maladies for which peripharyngeal abscess is most frequently mis- 
taken are laryngitis and simple but severe pharyngitis, From laryngitis, for 
which it has been most frequently mistaken, it may be distinguished by the 
dysphagia and by the character of the initial symptoms. In laryngitis there 
is usually the peculiar cough from the first or very early, while in abscess 
there is an initial period of several days, or even weeks, before respiration is 
materially affected. This is the period of inflammation which precedes sup- 
puration. 

In abscess, pressure of the larynx backward is badly tolerated, greatly 
increasing the dyspnoea, while in pharyngitis and croup this effect is not so 
marked. In abscess the horizontal position aggravates the dyspnoea, but not 
in pharyngitis and croup. The character of the voice also aids in diagnosti- 
cating an abscess from laryngitis, since in the former it is usually nasal, and 
in the latter hoarse and whispering. But the decisive test is afforded by 
inspection and digital exploration. The tumor is seen — or, if situated too 
low to be seen is felt — upon the walls of the pharynx. 

If the symptoms of abscess are masked by those arising from the cerebro- 
spinal system, as by convulsions, the priority of the pharyngeal symptoms 
aids in determining the true disease. 

In a case of suspected abscess the physician should not only carefully 
inspect the fauces, but should also employ digital examination. The finger 
will often detect fluctuation before the abscess is apparent to the eye. 

Prognosis. — With proper treatment the result is usually favorable, but 
if the disease be not recognized, many die. In Dr. Allin's cases, of those 
under the age of twelve years, 9 died, while 10 recovered by the opening of 
the abscess by the lancet, trocar, or finger, and 1 by its spontaneous rupture. 



708 LOCAL DISEASES. 

If the abscess be due to disease of the spinal column, death may occur 
immediately after the sac is opened, the caries of the intervertebral cartilages 
producing, according to Dr. Allin, dislocation of the vertebrae. Death may 
also occur, though rarely, from pleuritis, in consequence of the bursting of 
the abscess into the pleural cavity. Even in caries, if the sac be properly 
opened, and if need be reopened, and the head supported by suitable appara- 
tus, recovery is possible, as in a case treated by Prof. Post. 

Treatment. — The proper treatment of peripharyngeal abscess is simple, 
consisting in breaking or puncturing the sac by the finger, the lancet, bis- 
toury, or pharyngotome. Each method has been successfully employed. In 
the majority of cases the proper way to open the abscess is by the ordinary 
curved scalpel or bistoury, which should be covered by a strip of adhesive 
plaster to within half an inch of the point. If the abscess be postpharyngeal, 
it should be opened in the median line. A single incision suffices to evacuate 
the pus. If the abscess point or be elastic, there is little danger of wound- 
ing any important vessel or producing dangerous hemorrhage if the operation 
be properly performed, It may be necessary to open the abscess more than 
once, as in a case reported by Dr. Post and another which I saw with Dr. 
Livingston of this city. In certain cases, when the knife cannot be readily 
employed, the abscess may be opened by pressure with the finger-nail or the 
edge of a teaspoon. At the moment of puncture the child's head should be 
thrown forward, so as to give free escape to the pus externally. 

When, as in caries of the cervical vertebrae, the abscess is deep-seated and 
causes external prominence, it may be more successfully and safely opened by 
an external incision in the following manner (Chiene) : 

Commence the incision one inch below the mastoid process, and immediately 
behind the posterior border of the sterno-mastoid muscle, and extend it about 
one inch in length, down to and dividing the deep fascia ; with a blunt direc- 
tor the dissection is continued and the abscess opened, one finger pressing on the 
wall of the pharynx through the mouth. The pus may be evacuated by pressure 
on the pharynx. The cavity should be thoroughly cleansed by the douche, using 
the bichloride solution (1 : 5000). The cavity should not be scraped, but the drain- 
age-tube should be inserted so as to reach the most dependent place. Recovery is 
usually entirely satisfactory. 

Patients with this disease ordinarily require constitutional treatment, 
especially the use of tonics, ferruginous and vegetable. The citrate of iron 
and quinine, the citrate of iron and ammonium, and in strumous cases the 
syrup of the iodide of iron with cod-liver oil, are eligible preparations. Nutri- 
tious diet and often alcoholic stimulants are required. 

Swallowing Foreign Substances. 

The child is very liable to swallow such articles as buttons and pennies 
which have been given it. Parents are often greatly alarmed, but usually 
these small round bodies are harmless. It is well to advise giving a large 
supply of soft food, as bread and potatoes, and after a few days add a dose 
of castor oil. 

If the foreign body is thin and pointed, as a pin, needle, fish-bone, bristle, 
it most frequently sticks between one or other of the pillars of the fauces 
and the tonsil, or in the mucous folds connecting the base of the tongue 
with the epiglottis ; if more bulky, it is arrested at or about the junction of 
the pharynx and the oesophagus. The symptoms of a small pointed body in 
any of these positions are — local pain, with a pricking, increased on pressure, 
behind the angle of the jaw ; sometimes there is difficulty or pain in swal- 
lowing, with a disposition to vomit ; when it is at the upper orifice of the 



CATARRHAL PHARYNGITIS, ETC. 



709 



larynx, there may be cough and dyspnoea ; if the body is large, it usually 
causes death. In every case, instead of wiping the parts roughly with a 
sponge, make the most careful attempts to discover and remove the body ; 
if it is small and not detected by the sight or finger, use a laryngeal mirror, 
requiring the patient to inspire deeply while the tonge is depressed ; when 
found, seize it with properly curved forceps (Fig. 203). Or, employ the 
bristle probang (Fig. 204), which must be introduced, closed, below the for- 
eign body, then spread out and slowly withdrawn. If the obstructing body 
is food, dislodge it with the finger, or by inverting the trunk, as of a child, 
and giving to the back in that region a smart blow, or by forcing it down- 
ward with a probang (Fig. 205). If asphyxia is threatened, perform trach- 



Fig. 203. 



Fig. 204. 



Fig. 205. 





Pharyngeal forceps. 



Bristle probang. 



19 



Probands. 



eotomy or laryngotomy. If the body is irregular and too firmly impacted 
to be removed without dangerous violence, open the pharynx, even though 
severe symptoms are present. Pharyngotomy and cesophagotomy have the 
same details. 

If the body passes beyond the pharynx, it is most liable to lodge oppo- 



Fig. 206. 



Fig. 207. 




G.TIEMANN-CO. 



Probang forceps. 




Irregular curved 

forceps. 



site the cricoid cartilage, or just above the diaphragm, where the tube is 
most constricted ; if small in bulk, but pointed, as a needle, it may stick in 
the mucous membrane a long time, or loosen easily by ulceration, or pone- 



710 LOCAL DISEASES. 

trate the walls ; if large, hard, and irregular, deglutition is generally difficult 
and serious results are early threatened. The diagnosis depends upon the 

Fig. 208. 





Right-angled forceps. 

history. External palpation rarely gives any assistance in ascertaining the 
presence of a foreign body lodged in the oesophagus ; the tube lies so deep 
behind the trachea and below all of the muscles of the neck that the hardest 
and most irregular substances lodged in it can very rarely be appreciated by 
external examination. 

Attempt prompt removal ; if the substance be digestible, endeavor to force 
it onward into the stomach by the probang ; if indigestible, attempt to with- 
draw it by means of forceps having a suitable curve (Figs. 206, 207, 208). 
Introduce them, well oiled, with the blades closed, using them as a probe, 
until the object is reached, when they should be opened and an attempt be 
made to seize the foreign body ; if successful, the most careful manipulation 
is necessary in withdrawing it to avoid lacerating the mucous membrane ; 
if the body is small, use a probang to which a dry sponge is fastened, or a 
sound to which a skein of silk is attached, so as to form a snare with a great 
number of loops, or the bristle probang (Fig. 204). These instruments should 
be passed beyond the obstruction and gently rotated during its withdrawal. 
Coins and such bodies may often be extracted with a flat blunt hook con- 
nected by a thin strip of steel to the end of a long whalebone probang (Fig. 

209). Vomiting induced by titillating the 
Fig. 209. fauces or injecting apomorphia into the arm 

will sometimes dislodge a small body, but 
if the obstruction is firm, excessive vomit- 
ing may fix it more firmly or rupture the 
oesophagus. If respiration is dangerously 
embarrassed, tracheotomy must be per- 
formed, and if the obstruction is below 
the point of operation, a tube must be 
Hooks for extracting coins. carried down the trachea sufficiently to 

admit the air to the lungs. When, how- 
ever, a solid substance, though only of moderate size and irregular shape, 
has become fixed at the commencement of the oesophagus or low down in 
the pharynx, and has resisted a fair trial for its extraction or displacement, 
its removal should at once be eifected by incision into that tube, though no 
urgent symptoms are present. 

(Esophagotomy for the removal of a foreign body is not difficult, especially 
when the body can be located by external pressure : 

Place the patient, fully anaesthetized, on the back, the head and shoulders 
slightly elevated and face turned to the opposite side. If the foreign body pro- 
ject, make the operation at that point ; if not, operate on the left side, to which 
the oesophagus inclines. Make an incision in the course of the depression between 
the sterno-mastoid and the trachea, extending from about opposite the upper bor- 
der of the thyroid cartilage nearly to the sterno-clavicular articulation, through the 
integument (Fig. 210) ; divide the platysma myoides muscles and the cervical 
fascia; separate the edges of the wound and draw the omo-hyoid muscle out- 




CATARRHAL PHARYNGITIS, ETC. 



711 



Fig. 210. 




ward or cut it ; divide the outermost fibres of the sterno-hyoid and thyroid to a 
sufficient extent, 3 ; the carotid sheath, 2, is now fully exposed, and should be 
drawn outward with the sterno-mastoid and retained ; separate 
the thyroid body as far as it may be necessary with the handle 
of the' knife and draw it inward ; now draw the larynx some- 
what forward, turn it slightly upon its long axis, and pass the 
finger behind it to discover the position of the foreign body. 
If it is not found, pass a pair of long curved forceps well down 
into the pharynx through the mouth, open them so as to press 
the walls of the tube well toward the wound as a guide, care- 
fully avoiding the recurrent laryngeal nerve 5 open the tube, 
1, sufficiently to admit the finger, and extend the cut upward 
into the pharynx, 4, or downward along the oesophagus, as may 
be necessary to reach the object sought; search for the foreign 
body with the finger, and when found extract it by means of 
suitable forceps. The wound should not be closed with su- (Esophagotomy. 
tures. For the first few r days the patient should be fed by 
the rectum, but later through a tube passed by the mouth below the wound. 

Stricture of the oesophagus in children is generally due to cicatrices 
caused by attempts to swallow hot or corrosive fluids. It occurs chiefly on 
a level with the cricoid cartilage or the bifurcation of the trachea. It may 
be linear, annular, or tubular, or the cicatrix may embrace only part of the 
circumference of the tube and thus form a rigid valve-like projection. The 
leading symptom of organic stricture is gradually increasing difficulty of 
deglutition, with its concomitant distress and pain. If the patient is thin 
and the stricture high, it may sometimes be felt externally. To determine 
its presence and peculiarities, place the patient in a sitting posture, with the 
head thrown back, and pass an olive-pointed oesophageal bougie along the 
posterior wall of the pharynx down the tube to the seat of obstruction : 
the extent and condition of the stricture can thus be made out. The 
diagnosis in the early period depends upon the history. 

The treatment of the cicatricial form is by dilatation, cesophagotomy, or 
oesophagostomy. Dilators are made of different graduated sizes, of hard 
rubber, cylindrical, tapering at both ends alike, and securely fastened to a 
whalebone stem (Fig. 211) ; they 

may be held in the stricture for a Fig. 211. 

short time at each introduction, 
giving the benefit of pressure ; 
the tolerance of these bougies by 
the oesophagus gradually increases, 
though their pressure against the 
larynx may interfere with respira- 
tion and prevent their long retention 
within the stricture. 

Place the patient in a chair with 
the head thrown back. Now depress 
the tongue with the finger or a spatula, 
and, holding the bougie as a pen, pass 

it along the posterior wall of the pharynx down to the obstruction, and gently 
insinuate the conical extremity into the contracted passage. Apply the gag to keep 
the mouth open. The force used should be slight, lest the wall of the tube be per- 
forated, as has been done. The object is to open the stricture laterally and not 
push it downward : repeat the operation every second or third day, gradually 
increasing the size of the bougie as the stricture is enlarged. If the stricture is 
unyielding and deglutition impossible, gastrostomy must be performed. 

Sands says : " Gradual dilatation is usually the safest and best mode of treat- 
ment whenever it is practicable ; it should always be resorted to as a preventive 
measure in the incipient stage of the disease before cicatrization has occurred : as 




(Esophageal dilators. 



712 LOCAL DISEASES. 

a rule, treatment should be commenced within a week or ten days of the injury and 
continued indefinitely." 

(Esophag ostomy is the establishment of a fistulous opening in the neck 
for the relief of stricture of the oesophagus. It should never be performed 
unless there is reason to believe that it will be possible to introduce a tube 
into the gullet below the seat of stricture. The advantages are that it is 
attended with little shock and facilitates the subsequent dilatation of the 
stricture ; the disadvantages are — the doubt whether the opening will be 
below the stricture, the adhesion of diseased parts to surrounding structures, 
and the difficulty of operating in the vicinity of large vessels, nerves, and the 
thyroid gland. 

The operation is as follows : Place the patient on his back with his shoulders 
somewhat raised and his head turned toward the right side ; an anaesthetic having 
been given, standing behind the patient's head, make an incision through the skin 
oil the left side from just above the sterno-clavicular articulation to about the level 
of the hyoid bone ; cut the platysma, and if a vein of any size, such as the external 
or anterior jugular, is met with, divide it between two ligatures and turn aside ; slit 
the superficial fascia on a grooved director along the line of the original incision, 
and lay bare the anterior edge of the sterno-mastoid ; the patient's head should 
then be slightly raised, so as to relax the tissues of the neck, and an assistant 
should draw aside the sterno-mastoid with a retractor ; the omo-hyoid (which can 
be recognized by its direction inward and upward) is now brought into view, 
and should be divided as near to its hyoid insertion as possible ; the carotid sheath 
is next to be held aside, together with the sterno-mastoid, whilst the trachea is 
drawn inward by a second assistant ; the connective tissue being torn through with 
the handle of the knife, the left lobe of the thyroid body should be raised and 
pushed toward the middle line, when the trachea will be fully exposed, together 
with the oesophagus behind it. 

When the tube has been opened, a silk ligature should be passed through each 
edge of the oesophageal wound, and again through the corresponding lip of the 
cutaneous incision, and the gullet should be gently drawn toward the surface and 
loosely attached to the outer wound. A curved tube measuring about three inches 
in length below and one above the bend, with a suitable shield at its upper extremity, 
should be introduced into the oesophagus through the wound and fixed in position 
by means of tapes round the neck. Sutures may be used to bring the edges of the 
skin-wound together above and below the feeding-tube should this appear desirable. 

(Esophagitis. 

Disease of the oesophagus in infancy and childhood is comparatively rare, 
inflammation being the most frequent affection of this portion of the diges- 
tive tube in these periods, and, indeed, the only one which claims attention. 
It is most common in infants under the age of three or four months who are 
deprived of the breast-milk and are given a diet which is with difficulty 
digested, and perhaps taken too hot or too cold. It is therefore most com- 
mon in foundling hospitals. I have frequently observed it in the Infants' 
Hospital and the Nursery and Child's Hospital of this city, chiefly at the 
autopsies of bottle-fed infants under the age of six months whose symptoms 
had indicated disease or derangement of the digestive function. Many of 
them had diarrhoea and died in a state of emaciation. Oesophagitis in these 
cases was associated with simple or gangrenous stomatitis, thrush, or with 
gastritis or entero-colitis. Sometimes all these inflammations coexisted. In 
a few cases the confervoid growth of thrush had extended from the mouth 
to the oesophagus. It occurred in small hemispherical masses scarcely as 
large as a pin's head. Swallowing corrosive or strongly irritating substances, 
as the acids or alkalies, is an occasional cause of oesophagitis, the irritant at 
the same time producing stomatitis and gastritis. 



CATARRHAL PHARYNGITIS, ETC. 713 

Anatomical Characters. — The inflamed surface sometimes presents a 
uniformly injected appearance. Usually, however, there is greater intensity 
of the inflammation in streaks or patches than over the surface generally. 
I have frequently observed at autopsies a greater degree of inflammation in 
the lower than in the upper half of the oesophagus, even when the infant 
had stomatitis at the time of death. 

(Esophagitis occurring from faulty regimen or antihygienic conditions is 
not accompanied by as much thickening of the walls of the tube as often 
occurs in some other portions of the digestive canal ; as, for example, in the 
colon. Diphtheritic inflammation of the oesophagus is accompanied by so 
great infiltration of the mucous membrane and underlying connective tissue 
that I have seen the oesophageal walls three or four times the normal 
thickness. 

Occasionally ulcerations of the oesophageal mucous membrane are observed 
in the lower part of the tube, and Billard describes the ulcerative form of 
oesophagitis. At the first autopsies at which I observed these ulcers I sup- 
posed that they were pathological and indicated a severe grade of inflamma- 
tion : but a more extended observation has convinced me that they are 
usually post-mortem, and are not at all dependent on inflammation of the 
oesophagus. The solvent power of the gastric juice not only causes ulcera- 
tion in the stomach, but, entering the oesophagus, may and not infrequently 
does produce a solvent action on the mucous tissue there in the cadaver. At 
the meeting of the London Pathological Society, March 4, 1852, Dr. Graily 
Hewitt presented a specimen in which the gastric juice had not only eaten 
entirely through the coats of the oesophagus an inch above the stomach, but 
had even attacked the left lung. Over the age of six months inflammation 
of the oesophagus is rare. 

The symptoms of oesophagitis in young and emaciated infants, in whom 
it ordinarily occurs, are not well pronounced, Pain in deglutition or tender- 
ness on pressure over the oesophagus, if present in these infants, is ordinarily 
not appreciable, nor have they seemed to me to vomit oftener than other 
infants of this class who suffered from indigestion and gastro-enteritis with- 
out oesophagitis. It is therefore difficult to diagnosticate oesophagitis in them. 
It is, according to my observation, oftener present than absent in spoon-fed 
infants of three months or under who have persistent stomatitis and entero- 
colitis. 

Treatment. — In the oesophagitis of foundlings and ill-nourished infants, 
which arises, as has been stated, from faulty regimen, no treatment is required 
apart from that designed to relieve the stomatitis or entero-colitis with which 
it occurs. Attention must be directed mainly to the diet and hygienic man- 
agement. The remedial measures proper for such patients are more fully 
detailed in our remarks on entero-colitis. (Esophagitis produced by swallow- 
ing corrosive or highly irritating substances requires the same treatment as 
in the adult — to wit, poultices, demulcent drinks, etc. 



714 LOCAL DISEASES. 



CHAPTER Y. 

INDIGESTION, CONGESTION OF STOMACH, GASTEITIS, FOLLICULAK 
GASTKITIS, DIPHTHEKITIC GASTEITIS. 

Indigestion. 

Indigestion is more common during infancy than in any other period of 
life. While the digestive organs in the adult readily assimilate a great 
variety of food, it is necessary for the well-being of the infant that its diet 
be simple and carefully prepared. Departure from this rule leads to indiges- 
tion and ulterior diseases. 

After the age of two years a mixed diet is readily assimilated, the digestive 
function is less frequently disordered, and indigestion presents few peculiarities 
to distinguish it from that of the adult. 

Indigestion in some children is habitual ; in others the digestive process is 
ordinarily well performed, but from some temporary derangement of system 
or error of diet an acute attack of indigestion occurs. Hence, two forms of 
this ailment may be described ; first, acute, referring to temporary attacks ; 
secondly, chronic, referring to the habitual state. The subject of the diges- 
tion in infancy and childhood is treated of in other chapters of this book, to 
which the reader is referred. 

In the majority of cases of indigestion the fault does not exist in the 
child. It is fed too often or irregularly or upon a diet that is unwholesome 
or indigestible. It is well known that the milk of the mother or the wet- 
nurse is liable to changes which render it for the time unsuitable for the 
infant. Her food may be of such a quality, or her mind so excited, or some 
function of her system so disordered, as to effect a temporary change in the 
constitution of her milk. The occurrence of the catamenia or of gestation 
in mothers who are suckling not infrequently produces this unfavorable 
result. 

The most common cause of indigestion in the infant is artificial feeding. 
This, in the cities, is productive of a great amount of gastric and intestinal 
derangement and disease. The younger the infant the less frequently does it 
thrive if brought up by hand. 

Whatever care may be bestowed in the preparation of its food, whether 
cow's or goat's milk or farinaceous substances be used, there is seldom that 
healthy nutrition which is observed in infants who receive the breast-milk. 
The " swill-milk " in common use among the poor families of this city is 
totally unfit for the feeding of infants, and is apt to cause flatulence, acidity, 
and indigestion. Acute indigestion occurs in children of any age from food 
unsuitable in quality or quantity, which produces gastralgia and other symp- 
toms to be detailed hereafter. Those who suffer habitually from malassimila- 
tion are especially liable to such acute attacks. 

In the period of childhood, chronic indigestion is much less frequent than 
in infancy, but children are perhaps more subject than infants to the acute 
form. This is induced by ingesta taken in too large quantity or of a kind 
which is with difficulty digested. Cherries, currants, raisins, and the paren- 
chyma of oranges and lemons, dried fruits, and confectionery, which are so 
often heedlessly given to children, are common causes of acute attacks of 
indigestion. These substances, being but partially digested or not at all, and 
sometimes accumulating for days in the stomach or intestines, may lead to a 
very serious and dangerous condition. 



IXDIGESTIOX, ETC. 715 

Symptoms. — Vomiting is a symptom that should always arrest attention 
and its cause be ascertained. If the child cease to grow and lose its vivacity, 
the vomiting has pathological significance. Frequent vomiting, without other 
marked symptoms referable to the digestive apparatus, and with evident loss 
of flesh and strength, is in most cases a symptom of gastric indigestion or 
of incipient meningitis. The presence of mucus in the ejected matter, 
eructation of gas, and the apparent absence of headache and of other menin- 
geal symptoms apart from the vomiting, aid in establishing the diagnosis of 
gastric indigestion. 

The nursing infant, if the milk continually disagree with it, is fretful. 
It has a discontented aspect ; it seldom smiles, and is not amused by playthings 
or is only amused for a short time. Its features are pallid and bear the appear- 
ance of faulty nutrition. Its body and limbs are more or less wasted or are 
soft and flabby. Vomiting is frequently present, and sometimes a large mass 
or masses of casein are ejected which have evidently lain a considerable time 
in the stomach. The bowels may be constipated or loose and the evacuations 
are unhealthy. This state of the infant, continuing, prevents the necessary 
rest of the mother, and may affect unfavorably her health, so as to reduce the 
quantity of her milk or render it still more unwholesome. 

In habitual indigestion of young children fermentation of the food occurs 
to a great extent, instead of normal digestion, and the fermentation results 
in the production of acids. Whatever irritates the gastro-intestinal surface 
causes an increased secretion of mucus, and it is believed that the mucus, 
since it is alkaline, prevents to a great extent the digestive action of the 
pepsin, which requires an acid medium, so that lactic, butyric, and the fatty 
acids result. This acid fermentation, beginning in the stomach, extends to 
the intestines as the food is carried downward. Hence the acid breath, 
sour-smelling ejecta, fetid stools, flatulence, and colicky pains, indicating 
both gastric and intestinal dyspepsia, so common in young, improperly-fed 
infants. 

Habitual indigestion is, as might be expected, more common and severe 
in artificially fed infants than in those at the breast, and it is more likely to 
result in gastro-intestinal catarrh. In rural localities, where children are 
much of the time in the open air, have good constitutions, active digestion, 
and fresh food, dyspepsia is comparatively rare, but in large cities, in which 
the conditions of life are so different, its occurrence is common. Gross care- 
lessness in the feeding, and ignorance on the part of mothers of the dietetic 
requirements of young children contribute greatly to its frequency. 

Attacks of acute indigestion not infrequently occur from careless and 
improper feeding in children who are habitually dyspeptic, as well as in those 
whose digestive function is usually well performed. In these acute attacks 
young children, especially infants, often suffer much from colicky pains, 
gastralgia, or enteralgia. Their countenances indicate suffering ; they utter 
sharp cries ; their thighs are flexed over the abdomen and moved from side to 
side. Warm spirituous lotions, friction or gentle pressure upon the abdomen, 
give some relief, especially if they be attended by the expulsion of flatus. 
Vomiting or an evacuation of the bowels commonly removes the offen ding- 
substance, and the pain subsides. 

Attacks of acute indigestion come on suddenly, and occasionally are so 
severe that they produce dangerous symptoms, as eclampsia. Apart from 
pain or a sensation of weight or fulness in the abdomen, symptoms of a reflex 
character frequently occur, such as headache, drowsiness or languor, sudden 
twitching of the limbs premonitory of convulsions, and even severe or repeated 
convulsions. One of the most severe attacks of eclampsia which I have seen 
occurred in a boy of eight or ten years, induced by swallowing the pulp of 



716 LOCAL DISEASES. 

oranges which he had been in the habit of eating, and which had accumulated 
in the stomach and intestines. The expulsion of the offending substance 
gave immediate relief. In some children with acute indigestion the pulse is 
notably accelerated, the face flushed, the surface hot, and the temperature 
elevated two or three degrees above normal. 

As the child advances in years and becomes stronger its digestive func- 
tion is more active, a greater variety of food can be assimilated, and indi- 
gestion, whether temporary or habitual, is less frequent than in the first years 
of life. 

Prognosis. — Indigestion in the adult, when not due to organic disease, 
involves little danger to life, but in infancy its consequences are often serious. 
Habitual indigestion in the infant, whether due to the bad quality of the 
breast-milk or to artificial feeding, is liable to cause inflammation of the buc- 
cal, oesophageal, gastric, or intestinal mucous membrane, and in some patients 
of two or more of these divisions of the intestinal tract. Thus, especially 
in the warm months, the fermenting products of indigestion often cause 
dangerous catarrhal inflammation, accompanied by vomiting and frequent 
stools. 

Many cases of atrophy in infants, characterized by arrested growth and 
gradual loss of flesh and strength, till perhaps the features have a sunken 
and senile appearance from the waste and the skin lies in wrinkles, originate 
in habitual indigestion. Henoch points out the frequency of gastro-malacia 
in infants who have suffered from severe dyspepsia accompanied by the abun- 
dant production of acids. The softening of the stomach is believed to be 
largely, if not entirely, cadaveric, the result of post-mortem digestion from 
the presence of pepsin and the acids of fermentation. The gastric mucous 
membrane can be readily scraped away by the nail, and it presents a gelatini- 
form appearance. Sometimes even the stomach is perforated and the adjacent 
organs are acted on by the corrosive liquids. 

If the dyspepsia have not continued so long as to cause inflammatory 
complications, prompt recovery is probable by the use of suitable food and 
corrective medicines. If such complications be present, recovery can only 
be gradual. 

Diagnosis. — Habitual indigestion does not usually continue long without 
the occurrence of more or less gastro-intestinal catarrh. The poor nutrition 
and appetite, the unhealthy, flatulent stools containing mucus, the vomiting 
and occasional colicky pains, are symptoms which plainly indicate a dyspeptic 
origin. Attacks of acute indigestion are also easily diagnosticated, in most 
instances by the sudden occurrence of the symptoms, such as vomiting, pain 
in the abdomen or a sensation of fulness, eructation of gas, etc., and the 
speedy subsidence of symptoms when the cause is removed. But sometimes, 
especially in children over the age of two or three years, the symptoms may 
so closely resemble those of other acute diseases that a careful examination 
is required in order to make a clear and correct discrimination. Thus I have 
related above the history of a case in which the high temperature and expira- 
tory moan closely resembled those of pneumonia, but the symptoms quickly 
abated on the expulsion of a considerable quantity of orange-pulp. An 
attack of acute indigestion, attended by vomiting, rapid pulse, elevated 
temperature, with perhaps some erythema, may be mistaken for the com- 
mencement of one of the febrile diseases to which children are so liable. 
If on examination of the fauces no redness of the throat be observed, scarlet 
fever and diphtheria can be excluded. By a free evacuation of the bowels 
the symptoms abate and the attack ends, so that if there were any doubt in 
the diagnosis it is soon dispelled. 

When eclampsia results from an attack of acute indigestion, the physi- 



INDIGESTION, ETC. 717 

cian is often compelled to act promptly without a clear diagnosis, but the 
result of treatment soon renders the nature of the attack apparent. 

Treatment. — The first indication in treatment is obviously the removal 
of the cause. In acute indigestion, when there is reason to believe that there 
is some offending substance in the stomach or intestines, if the symptoms 
occur soon after the substance is taken an emetic may be administered, and 
ipecacuanha, in syrup or powder, is a safe and usually efficient remedy. If 
several hours have elapsed a purgative should be given, as castor oil, either 
alone or in combination with syrup of rhubarb, or an enema of glycerin and 
water may be employed. 

If the symptoms be urgent, especially if convulsions be threatened, we 
should not wait for the slow action of a purgative, but should resort at once 
to an enema to open the bowels. Sometimes the pain in acute indigestion 
is such as to require immediate treatment. I have found in such cases five 
to ten drops, according to the age, of the spiritus anisi, a very useful remedy. 
The following mixture will be found useful in such cases : 

R. Bismuth subnitrat., ^ij ; 

Wveth' s elixir of digestive ferments, Jjj ; 

Aquae anisi, ^iij. — Misce. 

Shake bottle. Give one teaspoonful every two to three hours if in pain from 
indigestion. 

If in the acute indigestion of infants diarrhoea occur, the camphorated 
tincture of opium, in combination with bismuth and pepsin, may be given. 
Infants, whose diet consists largely of cow's or goat's milk, digest with most 
difficulty the casein, which often passes the bowels in an imperfectly digested 
state, or it collects in a large and firm mass in the stomach, causing gas- 
tralgia and rendering the child fretful till it is vomited. I have elsewhere 
recommended, as important to prevent these attacks of acute dyspepsia, the 
use of the upper third of the milk, which contains less than the average 
casein. The addition of a little farinaceous food, as barley-water, to the 
nursing-bottle will sometimes produce the same effect by mechanically sepa- 
rating the particles of casein. Peptonized milk, as recommended in our re- 
marks elsewhere, will also be found useful in certain cases, and also the em- 
ployment of a good preparation of pepsin at each feeding. 

In chronic indigestion the means of relief are different. They are two- 
fold : first, as regards change of diet ; secondly, measures to improve the 
digestive function. Spoon-fed infants, suffering from habitual indigestion, 
require the utmost care as regards the character of their food, its preparation, 
and the times of feeding. Often it is best, if practicable, to procure a wet- 
nurse, and sometimes removal to a more salubrious locality is followed at 
once by improvement in the digestive function. If the infant be already 
wet-nursed, the milk should be examined microscopically and otherwise, and 
inquiry should be instituted in reference to the health and diet of the wet- 
nurse. Sometimes a change of wet-nurse is advisable. (For facts and con- 
siderations bearing on this point the reader is referred to the chapters relating 
to regimen.) 

Children with chronic indigestion are occasionally much benefited by the 
moderate and judicious use of alcoholic stimulants. These should be given 
sparingly with their food, and should be discontinued as soon as the digestive 
function is fully restored. M. Donne and some other French writers recom- 
mended the habitual use of wine for infants even in a state of health, but 
there are reasons, moral as well as physical, why alcoholic stimulants should 
only be used as medicines and not in a state of health. 

If the case be one of simple or uncomplicated indigestion, one of the 



718 LOCAL DISEASES. 

pepsin preparations of the shops, and tonics may be employed. In many 
instances, however, especially in infancy, gastro-intestinal inflammation has 
supervened, and in such cases those remedies should be employed which 
exert a favorable — or at least not an unfavorable — effect on the inflamed sur- 
face over which they pass. 

In habitual indigestion remedies are obviously required which increase 
the quantity of the digestive ferments. The following will be found a use- 
ful prescription in cases of indigestion in which gastro-intestinal catarrh has 
supervened : 

R. Acidi hydrochloride dilut., gtt. xvj-xxxij ; 

Pepsini puri, in lamellis, 3J ; 

Bismuth, subnitrat., gij ; 

Syr. simplic, J;ss '■> 

Aquse destill at. , ^ iij . — Misce. 

Shake bottle, and give one teaspoonful before each feeding. 

The lactopeptin of the shops is also useful, and when diarrhoea accom- 
panies the indigestion the following may be prescribed : 

R. Bismuth, subnitrat., giij ; 

Lactopeptin, ,5ij ; 

Pepsini puri, in lamellis, Jj. 

Give as much as goes on a five-cent-piece to a child of ten months before each 
feeding. 

If the stools continue frothy and offensive on account of the fermenta- 
tion the following will be found beneficial : 

R. Salol or resorcin, gr. iv ; 

Syr. simplic., ^ss ; 

Aquae destill at., giss. — Misce. 

Dose : One teaspoonful every two hours to a child of one year. 

In children over the age of three or four years the vegetable tonics 
are often useful, as quinine in half-grain or one-grain doses. Iron may 
also be given, especially the milder preparations, as the citrate, in anaemic 
cases. 

Among the useful vegetable stomachics and tonics may also be men- 
tioned the compound tincture of cinchona, the compound tincture of gen- 
tian, the infusion of columbo, the fluid extract of columbo, and the fluid 
extract of cinchona. 

If chronic indigestion be complicated with gastro-intestinal inflammation, 
subacute or chronic, for this is the form which is usually present, there are 
still certain tonics which may be advantageously administered. Columbo 
and the compound tincture of cinchona are often useful in these cases, and 
of the chalybeates wine of iron or the citrate of iron and ammonium or the 
liquor ferri nitratis may be safely administered. In most cases, however, 
change in the diet properly made will be found more useful than tonic and 
corrective medicines. 

Infants affected with diarrhoea from indigestion often improve under the 
use of powders consisting of equal parts of subnitrate of bismuth and lacto- 
peptin. An infant of three months can take three grains of each every three 
hours or before each feeding, or it may take three or four grains of the sub- 
nitrate of bismuth with half a grain of pure pepsin in scales. 

Dyspepsia often rapidly disappears by hygienic measures without the use 



IXDIGESTIOX, ETC. 719 

of medicines, as by removal from the city to the country, out-door exercise. 
In infants also marked improvement is often observed on the approach of the 
cool and bracing weather of autumn and winter. 

Congestion of the Stomach. 

Passive congestion of the stomach is described among the diseases of this 
organ by Billard, but it is a pathological state of little importance in itself. 
It occurs in new-born infants asphyxiated at birth and with difficulty resusci- 
tated. In these cases there is generally intense capillary congestion through- 
out the system. The mucous membrane of the stomach is injected, but not 
more than that of the mouth or intestines. If circulation and respiration 
be fully established, the injection of the capillaries subsides. No treatment 
is required, except measures to promote the circulatory and respiratory func- 
tions. In cyanosis and atelectasis there is often general congestion of the 
capillaries of the systemic circulatory system on account of the obstruction 
to the flow of blood through the heart in the one disease and through the 
lungs in the other. There is in these cases passive congestion of the stomach, 
but not more than of other organs. 

Gastritis. 

Inflammation of the stomach, except when produced by the direct con- 
tact of some irritant, is rare in infancy and childhood independently of dis- 
ease in some other portion of the intestinal tract. Cases have, however, been 
reported in which it was not known that any irritating ingesta had been taken, 
and in which a careful examination revealed a healthy or nearly healthy state 
of other portions of the digestive tube. The subjects were for the most part 
young infants. The following is an example related by Billard : 

An infant, four days old, remarkable for the color of its face and firm- 
ness of flesh, refused the breast and vomited yellow, acid matter. On the 
following day the vomiting had increased, the legs were oedematous, face 
pallid and pinched, respiration difficult, skin cold, pulse slow and irregular, 
and pressure on the epigastric region produced cries indicative of pain. 
Third day : general sinking ; face thin and expressive of great pain ; stools 
natural. Fourth and fifth days : condition the same. Death occurred on the 
sixth day, and the autopsy was made on the day following. With the 
exception of slight pneumonia no disease was discovered in any part of the 
system besides the stomach. The mucous membrane of this organ was 
intensely vascular near the cardiac orifice and along the lesser curvature. 
This part was also tumefied, and could be easily raised with the finger-nail. 
The remainder of the gastric surface was hyperaemic, but to a less extent. 

This case is interesting as showing what may happen, though rarely. A 
nursing infant is seized with gastritis without apparently having taken any 
irritating ingesta and without other diseases of the digestive apparatus. It 
is probable, however, that in cases like the above the cause, if ascertained, 
would be found in the ingesta ; perhaps drinks too hot, perhaps elements 
of colostrum or pathological elements in the milk, which might produce 
gastritis in young infants, in whom the mucous membrane is delicate and 
sensitive. 

Gastritis is not uncommon in infancy in connection with inflammation of 
the intestines. The latter inflammation is sometimes apparently subordinate 
to the former, and if such patients die the fatal result is due mainly to the 
gastric disease. The reverse is, however, the rule. The gastritis is ordinarily 
subordinate to the intestinal catarrh. 



720 LOCAL DISEASES. 

Cause. — Gastritis, as I have observed it in infants, has been in most cases 
due in great part to the continued use of improper food — of food not suitable 
to the age of the child, and which was therefore with difficulty digested. 
Milk, acid or otherwise unwholesome, farinaceous substances, stale or of an 
inferior quality and not properly prepared, drinks too hot or too cold, may be 
specified among the causes. Therefore this disease is most common in bottle- 
fed infants, and is comparatively rare in those who receive abundant and 
wholesome breast-milk. Antihygienic agencies, apart from the diet, no doubt 
exert some influence in the production of gastritis, as they do of stomatitis. 
Uncleanliness and residence in damp and dark apartments or in an atmosphere 
loaded with noxious gases produce a condition of system which strongly pre- 
disposes to these inflammations, if indeed, they may not be enumerated 
among the direct causes. 

Eilliet and Barthez have called attention to the fact that certain medicinal 
substances given to children occasionally cause gastritis. They have observed 
this effect from the use of tartar emetic, kernies mineral, and croton oil. 
Gastritis occurring in this way may or may not be associated with inflamma- 
tion in contiguous portions of the digestive tube. Elsewhere I have related 
a case in which gastro-enteritis occurred in a child nine years old after having 
taken a considerable quantity of kerosene oil for spasmodic croup. 

Inflammation of the stomach is thought by some to accompany measles 
and scarlet fever during the eruptive period, but this opinion is probably 
incorrect. If it occur, it corresponds with the stomatitis and dermatitis of 
these diseases, and disappears as they subside. It is mild and accompanied 
by few symptoms. I have, as stated in the remarks on Scarlet Fever, exam- 
ined in certain instances the stomachs of those who have died during the 
eruptive periods of these diseases, and found them free from any appreciable 
inflammatory lesion. 

Age. — From the records of about seventy cases of inflammatory disease 
of the digestive mucous membrane which I have preserved it appears that 
gastritis is not common over the age of six months. On the other hand, it 
is common in infants under the age of three months who are deprived of 
breast-milk. I have met it chiefly in foundlings fed with the bottle, and hav- 
ing at the same time entero-colitis, and often also stomatitis and oesophagitis. 
In these cases there is sometimes continuous or almost continuous injection 
and thickening of the mucous membrane from the lip to near the pyloric 
orifice of the stomach, and even beyond this orifice in the intestines. 
The following is an example of gastritis as it frequently occurs in found- 
ling institutions : 

Case. — R. "W , female, two weeks old, was admitted into the New York 

Infant Asylum, August 24, 1865, anaemic and somewhat emaciated. She was in 
part wet-nursed and in part bottle-fed. The emaciation increased, and nearly the 
entire buccal cavity became covered with the confervoid growth of sprue. On 
September 4th diarrhoea commenced. Borax was used for the mouth and alkalies 
and astringents to check the diarrhoea, but without material improvement. 

The following was the record for September 7th : " Cries almost constantly, 
with feeble or whining voice ; still has thrush ; nurses and does not vomit ; 
stools five or six daily, and green ; pulse 130, feeble." Death occurred Septem- 
ber 8th. 

Autopsy, September 9th. — Mouth and fauces not examined ; mucous membrane 
of oesophagus vascular in its whole extent, with slight thickening, but without 
ulceration ; mucous membrane of stomach hyperaeniic, like that of the oesophagus, 
and somewhat thickened, except in its pyloric extremity, where the appearance was 
natural or nearly so ; the color in the central part of the inflamed gastric membrane 
was deep red ; no thrush was noticed except on the buccal surface during life ; 
along the great curvature of the stomach were white flakes resembling those of 
thrush, but which were found by the microscope to consist mainly of oil-globules 



INDIGESTION, ETC. 721 

and epithelial cells, -without the cryptogamic formation ; mucous membrane of small 
intestines healthy in its whole extent, except slightly increased vascularity in a 
few places in the ileum ; mucous membrane of colon much injected throughout, 
except near the ileo-caecal valve, where the vascularity was slight; in the trans- 
verse and descending colon the redness was pretty uniform, and the membrane 
was thickened, but not ulcerated ; solitary glands and Peyers patches moderately 
elevated. 

The observations of Valleix show how frequently gastritis is associated 
with severe attacks of thrush. In 23 of his cases of the latter disease in 
which the condition of the stomach was noted after death this organ pre- 
sented inflammatory lesions in 17, and in 3 others appearances which may 
or may not have been due to inflammation. 

Symptoms. — A difficulty exists in isolating and defining the symptoms of 
gastritis, from the fact that it commonly coexists with other inflammations 
of the digestive tube. Though we may never be able to diagnosticate this 
catarrh as certainly as we can croup or pneumonia, still there are symptoms 
which arise directly from the gastritis, and with care we may be able to dis- 
tinguish them from those symptoms which are due to other pathological 
states. 

If gastritis be acute, pain is present. In the above case from Billard, 
as well as in a case observed by myself and related under the head of Gelat- 
inous Softening, there were frequent cries, and the countenance indicated 
much suffering until the stage of collapse. If there be less intensity of 
inflammation and the disease be more protracted, as is ordinarily the case, the 
pain is not so severe, and it may be so slight as not to attract attention. 
Sometimes there is tenderness, so that pressure upon the epigastric region is 
badly tolerated. Vomiting is regarded as one of the most constant symp- 
toms. The infant after nursing seems in distress till the milk is vomited, but 
it nurses with avidity in consequence of the thirst if it be not too exhausted 
or feeble. The dejections may be quite regular throughout the disease, as in 
the case from Billard. There is ordinarily, however, diarrhoea from the 
presence of entero-colitis. The pulse is sometimes accelerated and sometimes 
nearly natural. The emaciation in gastritis is rapid, since not only the nutri- 
ment is in great measure vomited, but the digestive function, so far as the 
stomach is concerned, is seriously impaired. The features become wrinkled 
and senile, the eyes hollow, the limbs attenuated, and the cranial bones 
uneven. Death occurs from exhaustion. 

Anatomical Characters. — Simple gastritis may affect the entire mucous 
surface of the stomach or be limited to a certain part. The part which is most 
likely to escape is that toward the pyloric orifice. This portion of the organ 
is sometimes found in nearly or quite the normal state, while the cardiac half 
or two-thirds is inflamed. The vascularity of the diseased surface is not uni- 
form. In one place there is simple arborescence ; in another intense continu- 
ous redness ; and between these two extremes are different grades of vascu- 
larity. The mucous membrane is somewhat thickened, softened, and the 
secretion of mucus increased. Extravasation of blood is not infrequent 
under the mucous membrane, usually in points, and the mucus may be mixed 
with more or less blood. Small shreds or portions of coagulated milk are 
often found with the mucus attached to the gastric surface. I have observed, 
though rarely, small superficial ulcers at the point where the inflammation 
had been most intense. 

Dr. A. Jacobi says : ' ; Indeed, the boundary-line between a simple dys- 
pepsia and a gastric catarrh is perhaps never made out clearly. The epithelium 
of the mucous membrane does not belong to it exclusively, but spreads in the 
contiguity of the tissues into the muciparous and the peptic glands. Thus 
46 



722 LOCAL DISEASES. 

the inflammatory condition of the surface becomes at once a parenchymatous 
affection, though it be possible that an uncomplicated catarrh and an uncom- 
plicated inflammation may have an occasional existence Unless a 

gastric catarrh or a dyspepsia .... be relieved at once, the merely func- 
tional or superficial disorder becomes organic and deep-seated. These changes 
may refer either to the tissue or the secretion. Inflammatory thickening, 
erosions, ulcerations, or (Moncorvo) dilatation of the stomach will be observed 
in a great many instances. The secretions become abnormal ; the normal 

hydrochloric acid of the gastric juice is almost invariably diminished 

Lactic acid, however, is produced in much larger quantities than the first 
stage of digestion requires, and with it acetic, butyric, and the rest of the 
fatty acids." 

Diagnosis. — In protracted cases, when entero-colitis is present, it is dif- 
ficult to make a positive diagnosis. Our opinion must then be little more 
than a plausible conjecture. In the acute attacks we can diagnosticate the 
gastritis with more certainty. If a young infant affected with sprue be 
seized with pain, and vomits often ; if emaciation be rapid and there be no 
diarrhoea, or diarrhoea not sufficient to account for the prostration ; if the 
buccal mucous membrane, dotted with the points of thrush, presents a dry 
appearance and the deep-red color of severe stomatitis, — there can be little 
doubt of the presence of gastritis. The diagnosis is rendered more certain 
by signs of tenderness when pressure is made upon the epigastric region. 

Prognosis. — like other inflammations, gastritis is probably sometimes 
so mild that it does not materially increase the suffering or danger of the 
child. This mild form of the disease under favorable circumstances soon 
subsides. In other cases, by the continuance or increase of the cause, the 
inflammatory process becomes more severe and extensive, resulting even in 
disintegration of the mucous membrane. Those cases are especially severe 
and likely to end fatally which are protracted and accompanied by severe 
thrush, with a desiccated appearance of the buccal surface or with entero- 
colitis. Pain, vomiting, and rapid emaciation in such children indicate the 
speedy approach of death. Improvement in the stomatitis or entero-colitis 
is a favorable indication, but these inflammations may improve without cor- 
responding improvement in the gastritis. 

Treatment. — All food or drinks except those of a bland and unirritating 
nature should be forbidden. If practicable, the young infant should have the 
mother's milk or that of a wet-nurse. If this be impossible, the reader is 
referred to the chapter on Infantile Alimentation for advice in relation to the 
feeding. Death occurs from exhaustion, and it is therefore important that 
the vital powers be not reduced. To relieve the thirst, and at the same time 
sustain the child, I have found half a teacupful of carbonic-acid water, Vichy 
water, or plain water, mixed with one teaspoonful of the liquid peptonoids of 
the Arlington Chemical Works or of Fairchild's panopepton, agreeable and 
useful to the patient. 

Follicular Gastritis; Diphtheritic Gastritis. 

The pathological character of follicular gastritis is similar to that of fol- 
licular stomatitis. It is an inflammation affecting the gastric follicles and 
ending in their ulceration. It is not a frequent disease ; it occurs in young 
infants. Billard observed fifteen cases. The symptoms in these patients 
were similar to those in simple gastritis of a severe form. The emaciation 
and prostration were rapid, and death occurred early. We can only diagnos- 
ticate the gastritis without determining its follicular character. How many 
recover it is impossible to ascertain, but the disease is likely to be fatal on 



GASTRO-IXTESTINAL BACTERIA. 723 

account of the intensity of the inflammation, not only of the follicles, but 
of the intervening mucous membrane. The treatment is that of gastritis. 

Diphtheritic gastritis is infrequent. It occasionally occurs during epi- 
demics of diphtheria. Allusion is elsewhere made to a case treated in the 
Nursery and Child's Hospital of this city in December, 1859. The patient, 
eighteen months old, had had previously protracted entero-colitis, and died 
exhausted after a brief attack of diphtheria. There were lesions referable 
to the entero-colitis, and the body was much emaciated. The diphtheritic 
exudation was found covering the fauces, epiglottis, glottis to the rim a glot- 
tidis. the entire oesophagus, and almost the entire stomach. The mucous 
surface underneath was injected; that of the oesophagus and stomach espe- 
cially was very vascular, softened, and thickened, and the submucous connec- 
tive tissue was infiltrated. 

The pseudo-membrane taken from the epiglottis and examined under the 
microscope presented an amorphous appearance ; no cells were noticed in it, 
and fibrillation was not distinct ; that from the stomach was found to consist 
almost entirely of cells. The digestive process, so far as the stomach was 
concerned, had evidently been almost if not entirely suspended, and hence in 
part the sudden prostration. Diphtheritic gastritis probably does not occur 
without general infection of the system with the diphtheritic virus. The 
proper treatment is the use of one of the solvents of pseudo-membranes 
which do not irritate the mucous membrane, while the constitutional treat- 
ment proper for diphtheria is employed. 

Dilatation of Stomach. 

The stomach may undergo abnormal dilatation, according to Dr. A. 
Jacobi, from overfeeding with bulky, especially amylaceous, food ; from 
diminished contractility in its muscular coat consequent on debility ; from 
imperfect digestion and flatulence ; from catarrhal gastritis and peritoneal 
adhesions. In its treatment he recommends medicines (as bismuth) which 
diminish fermentation, the avoidance of fats and starches and of large quan- 
tities of fluid ingesta. Milk may be given in small quantities and often. 
Raw beef, beef peptones, and peptonized milk are useful, as is also an 
abdominal binder. Faradic and galvanic currents have been used with some 
advantage, and the tincture of nux vomica or strychnia, gr. T l^ to T -l~g-, three 
times daily, will increase the contractility of the muscular coat of the 
stomach. 1 



CHAPTER VI. 

GASTRO-INTESTINAL BACTEEIA. 

Recent investigations have demonstrated that these organisms sustain an 
important causal relation to the indigestion, malassimilation, and diarrhceal 
diseases of infancy. They are minute unicellular bodies, and are classified 
as follows : first, the micrococci, or globular bacteria ; secondly, the bacilli, 
or rod-shaped bacteria ; and thirdly, the spirilla, or spiral bacteria. 

The pathogenic character of these bodies has been to a considerable ex- 
tent elucidated by the microscopic examinations and experiments of several 
European scientists, prominent among whom is Escherich, and by the inves- 
tigations of Booker and Vaughn in America. 

1 Arch, of Pediatrics, Aug., 1889. 



724 LOCAL DISEASES. 

Bacteria are not present in the stomach and intestines in the foetus, nor 
in the meconium at birth. They are conveyed to the digestive tract of the 
newly-born through the air and saliva and the liquid ingesta. and it is 
believed that they sometimes obtain entrance through the anus, for they 
have been found in the meconium three to seven hours after birth (Esch- 
erich). When the meconium is expelled the bacteria which it contains 
disappear, and other species subsequently take their place in the milk-feces. 
The feces of healthy nurslings contain a larger number of bacteria, of which 
the bacterium lactis aerogenes and bacterium coli commune are uniformly 
present. 

According to Booker, in the healthy suckling the stomach contains few 
bacteria, chiefly bacilli ; the duodenum also contains but few ; but they 
increase in number on tracing the intestine downward. On reaching the 
lower end of the upper third of the small intestine, we find a considerable 
number of bacteria, including diplococci, bacteria lactis aerogenes, and colon 
bacteria. The bacteria lactis aerogenes undergo no farther increase in the 
lower part of the small intestines and in the colon, but the colon bacteria 
(bacterium coli commune) undergo a great increase in number in the lower 
part of the ileum and in the colon. They exist in large numbers in the 
entire length of the colon, and of larger size than in the small intestine. 
The bacterium lactis aerogenes occurs in the form of " short, thick rods, with 
rounded ends." Injected into the blood of guinea-pigs and rabbits, it causes 
death, preceded by the phenomena of intestinal catarrh. The bacterium 
coli commune is believed to be always present in feces, whatever the diet. 
It is also rod-shaped, and it varies in size and length, the largest and longest 
specimens attaining the length of five micro-millimetres. According to 
Booker, both these microbes promote fermentation in the intestines. Many 
other forms of bacteria have been discovered in the milk-feces of infants, in 
addition to the two which we have described. Escherich discovered twelve 
varieties^ micrococci and bacilli. 

To the physician the gastro-intestinal bacteria are mainly interesting on 
account of the supposed causal relation which they sustain to certain abnor- 
mal conditions of the digestive tract, especially to the diarrhoeal affections. 
It is important in investigating this subject to ascertain what bacteria are 
present in normal feces, and whether they exert pathogenic action under cer- 
tain circumstances. This has been, in a measure, ascertained, as we have 
seen, but another interesting and important inquiry relates to new forms of 
bacteria that appear in the feces in diseased conditions of the stomach and 
intestines, and the causal relation which they bear to these conditions. New 
forms of bacteria may appear in the feces in gastro-intestinal disease without 
sustaining a causal relation to it or influencing it. Again, although not 
causing the disease, they may influence its course and duration, or they may 
cause gastro-intestinal disease by lodging in the food, especially in milk, and 
producing by their agency poisonous chemical substances in it before it is 
employed in the nursery. The well-known poisoning by the tyrotoxicon in 
the hotels at Long Branch, this poison being produced in milk probably by 
microbic action six or eight hours after the milking, was an instance of this 
kind. Again, a species of bacteria not occurring in the stools in health, but 
appearing in disease, as in indigestion, inanition, or diarrhoea, may be the chief 
factor in causing this morbid state. 

According to Booker, none of the gastro-intestinal secretions have an inju- 
rious effect on bacteria, except the gastric juice, but certain bacteria are 
antagonistic to others, so that their presence prevents the full development 
of the latter. Bacteria, which in the normal state of the gastro-intestinal 
tract do not find a soil suitable for their development in the stomach or 



GASTRO-ISTESTINAL BACTERIA. 725 

intestines, obtain the conditions favorable for their growth and propagation 
in diseased states, as when indigestion or catarrh is present. 

The pathogenic action of bacteria in the digestive tract can be most suc- 
cessfully investigated by experimenting with them when they have been iso- 
lated from other substances by repeated cultivations. Hay em and Lesage 
have isolated a bacillus which they have discovered in green stools of infants, 
and which they believe produce by its disturbing action the green color and 
abnormal state of the stools. The green color in the feces of infantile diar- 
rhoea they believe to be sometimes due to an excess of the bile-pigment, but 
in other instances is produced by the action of a bacillus, which occurs 
especially in the upper two-thirds of the small intestine, where it attains 
the length of two (o three micro-millimetres. Injected into the blood of 
sucking animals, this bacillus appeared in the duodenum ten or twelve hours 
subsequently, and, increasing in number, caused green discoloration of the 
intestinal contents. The same result was produced when this microbe was 
administered in the ingesta. In its dry state it floats in the air, so that when 
an infant having green stools produced by its action enters a ward, others are 
liable to be attacked with the green diarrhaea if its soiled diapers are allowed 
to dry in the room. 

Baginsky has investigated the stools in the acid diarrhoea of infants, and 
has isolated two forms of bacteria which liquefy gelatin. One of these pro- 
duces green coloring matter, and is probably the same as that described 
above ; the other was constantly present in the acid diarrhoeal feces, was 
poisonous to animals, and it is probably impotent in the pathogenic role. 
Baginsky believes from his observations that the bacterium lactis aerogenes 
present in the normal stools of the suckling is under favorable circumstances 
antagonistic to the development of pathogenic organisms. 

Dr. Booker has isolated forty bacteria from the stools of 30 infants, 
all seriously sick with diarrhoeal diseases, 11 having cholera infantum, 14 
catarrhal enteritis, and 5 dysentery. The largest number of these organisms 
occurred in cases of cholera infantum, and the next largest number in cases 
of catarrhal entero-colitis. According to Booker, the bacteria of the normal 
milk-feces still appear in the diarrhoeal stools. The bacterium coli commune 
was found by him in all the diarrhoeal cases, but its number appeared to 
diminish according to the severity of the attack. On the other hand, the 
bacterium lactis aerogenes occurred in larger number in the diarrhoeal stools 
than in healthy milk-feces. Booker discovered bacteria of the proteus group 
in 7 of the 11 cases of cholera infantum ; which is a matter of significance, 
inasmuch as Escherich did not find any bacterium of this group in normal 
milk-feces. 

In a very interesting and instructive paper read before the American 
Pediatric Society in June, 1890, Dr. Victor C. Vaughan detailed his experi- 
ments, which showed that " three micro-organisms, differing sufficiently to 
be recognized as different species, produce poisons, all of which cause vomit- 
ing and purging, and, when used in sufficient quantity, death" in cats and 
dogs experimented on. Dr. Vaughan concludes his paper with the following 
aphorisms : " 1. There are many germs, any one of which, when introduced 
into the intestine of the infant under certain favorable circumstances, may 
produce diarrhoea. 2. Many of these germs are probably truly saprophytic. 
3. The only digestive secretion which is known to have any decided germici- 
dal effect is the gastric juice. Therefore, if this secretion be impaired, there 
is at least the possibility that the living germ will pass on to the intestine, 
will there multiply, and will, if it be capable of so doing, elaborate a chemical 
poison, which may be absorbed. 4. Any germ which is capable of growing 
and producing an absorbable poison in the intestine is a pathogenic germ. 



726 LOCAL DISEASES. 

5. The proper classification of germs in regard to their relation to disease 
cannot be made from their morphology alone, but must depend largely upon 
the products of their growth." 



CHAPTER VII. 

SIMPLE DIARRHOEA. 

Diarrhcea is frequent during the whole period of infancy. French writers 
describe several varieties, according to the character of the evacuations, as 
acescent, mucous, and serous. M. Rostan even describes fourteen distinct 
kinds. But the tendency of medical science in modern times is to simplify 
the nomenclature of diseases — to describe under a single name those affections 
which are essentially the same, though differing somewhat in their features. 
Now, all the forms of diarrhoea in the infant may be so grouped as to reduce 
the number to not more than three or four. In this way repetition and 
prolixity are avoided, as well as an unnecessary refinement. 

The most common form of diarrhoea is that enunciated in our heading. 
But often a diarrhcea which is non-inflammatory at first becomes a catarrh. 
Thus the simple diarrhoea of infancy may become an entero-colitis from the 
continued use of improper diet. 

Causes. — These are various. Conditions or agencies which have no 
appreciable effect in the adult often increase the number of evacuations in 
young children. Food which imperfectly digests, and some of which perhaps 
ferments, stimulates the intestinal follicles to excessive secretion, and increases 
the peristaltic movements by its irritating action, thus causing diarrhoea. Too 
frequent and abundant feeding is another cause, especially in young infants, 
some of whom may vomit the surplus food and remain well, but others do 
not. Food which cannot be assimilated becomes an irritant in consequence 
of fermentative change, and produces frequent and unhealthy evacuations. 
In the light of our present knowledge we assign to the agency of intestinal 
bacteria an important causal relation to those forms of diarrhoea which are 
attended by fermenting, imperfectly-digested, and unhealthy stools. By the 
investigations of Booker and others it is now known that many forms of 
bacteria exist in the stools, and when abundant excite the vermicular and 
peristaltic movements so as to excite more abundant evacuations. 

The mother's milk or the milk of the wet-nurse may disagree, either 
from some temporary derangement of her system or continued ill-health, or 
from causes which are not understood. Diarrhoea in the nursling is the 
result. 

Fright or strong mental impressions will also in some children increase 
the number of evacuations. This cause being transient, the diarrhoea soon 
subsides. 

Another cause is exposure to cold. Children who are insufficiently clothed 
in the winter season, who are taken from a heated room into a cool one with- 
out sufficient protection, or who lie uncovered at night are very subject to 
diarrhoeal attacks from the impression of cold on the system. 

The cause of simple diarrhoea may exist in the child itself. In some 
children the evolution of the teeth is attended by a relaxed state of the 
bowels, which ceases when the gum is pierced, but whether it is a cause 
of the diarrhoea we are not prepared to state. Worms in the intestines may 



SIMPLE DIARRHCEA. 727 

also operate as a cause. Diarrhoea is occasionally salutary within certain 
limits, and of course it is not strictly correct to call it a disease when it 
is a means of relief. If occurring from excessive or irritating ingesta, it is 
obviously conservative. 

Symptoms. — Diarrhoea may come on suddenly ; at other times there are 
precursory symptoms continuing for some days. Whether or not there be 
antecedent symptoms depends chiefly on the cause. If this be exposure to 
cold or the use of improper aliment, it commonly occurs immediately. 

Among the prodromic symptoms sometimes present are restlessness, dis- 
turbed sleep, transient abdominal pains, nausea or vomiting, and other symp- 
toms of indigestion. The stools in simple diarrhoea differ much in color and 
consistence in different cases, and perhaps at different periods in the same 
case. In infants they are often green. This color, which is a source of 
anxiety to the inexperienced, and especially to the parents, is often produced 
by trivial causes. Slight indigestion will produce it, and so will excess of 
food, even when bland and unirritating. We have already stated that a cer- 
tain microbe has the power to produce the green color. The stools in infantile 
diarrhoea often contain particles of coagulated casein, but in children advanced 
beyond the period of first dentition they do not differ materially in appearance 
from the evacuations of the adult. They are usually passed easily, but if 
they be acid or in any way irritating there may be more or less tenesmus, 
especially in infants. Sometimes before the evacuations there is a sensation 
of fulness in the abdomen. In that form of diarrhoea which has been desig- 
nated acescent not only are the stools acid, but matters vomited have an acid 
odor and give an acid reaction. 

During the quiet hours of sleep, when no foods and drinks are taken, the 
diarrhoea diminishes. If the complaint be slight, there is little thirst ; but 
if the stools be frequent and thin, especially if they approach the watery 
character, the patient is thirsty. The appetite varies, the tongue is moist 
and covered with a light fur, and there is often more or less meteorism, 
but no abdominal tenderness. 

The features in this disease are pallid. In a few days, if the evacuations 
continue, there is evident loss of weight and flesh. The rotundity of the 
limbs is gradually lost and the tissues become soft and flabby. But in most 
cases when the malady has reached this stage its original character is lost, 
and it has become inflammatory. 

Certain epiphenomena, as Barrier terms them, occur at times in non- 
inflammatory as well as in inflammatory diarrhoea ; as, for example, a sym- 
pathetic cough or, which is more serious, cerebral complications. Convul- 
sions or stupor, indicating the supervention of spurious hydrocephalus, may 
occur in either form of diarrhoea. This disease is described elsewhere. More 
or less fever may occur in simple diarrhoea, but it is not constant and the 
pulse may or may not be accelerated. 

Anatomical Characters. — It is obvious from the nature of simple 
diarrhoea that it is attended by little or no perceptible anatomical change. 
In cases supposed to be simple or non-inflammatory, which have ended fatally 
either from the diarrhoea or an intercurrent disease, the most marked lesions 
observed have been more or less tumefaction of the intestinal glands, with 
perhaps diminished firmness and resistance of the mucous membrane. Cases 
like the following, which have usually been regarded as non-inflammatory, 
are not infrequent, but it seems probable that in at least a certain proportion 
of such cases the intestinal follicular apparatus has passed beyond the 
physiological state of an exaggerated functional activity, and that the dis- 
ease should be designated a catarrh or inflammation. Inasmuch as non- 
inflammatory diarrhoea, if protracted, is very liable to become inflammatory, 



728 LOCAL DISEASES. 

it is often difficult to determine whether the malady has undergone this 
change, even with the aid of post-mortem inspection. 

On the 7th of July, 1865, a foundling one month old died at the Infant 
Asylum. It was much emaciated, with eyes sunken and features pinched, 
at the time of its death. It was wet-nursed to the close of its life, but the 
nurse's milk was insufficient. It did not vomit, did not have any marked 
acceleration of pulse (128 per minute), and its evacuations were about four 
daily, and thin. The stomach and intestines were pale throughout. The 
solitary glands, particularly those in the colon, and the patches of Peyer 
were tumefied so as to be visible and somewhat raised above the surround- 
ing surface. But no lesions being observed which are characteristic of 
inflammation, the disease was regarded as non-inflammatory. 

Niemeyer, with others, describes even the mildest forms of diarrhoea under 
the term catarrhal inflammation, and he appears to consider the transient 
effects of a purgative as an incipient catarrh. But it seems to me prefer- 
able, in the present state of pathological knowledge, to regard all those diar- 
rhoeas which immediately abate with the removal of the cause, and which are 
attended by no marked anatomical change, as non-inflammatory or simple. 
They are characterized by increased secretion of the intestinal follicles and 
increased peristalsis. 

Prognosis. — In a large proportion of cases simple diarrhoea is not dan- 
gerous. With the adoption of suitable measures to remove the cause and 
the use of medicines to control the discharges the patient recovers. The 
remark already made may be repeated here, that occasionally diarrhoea is 
salutary within certain limits, as when there is a foreign substance in the 
intestines either irritating mechanically or by its chemical properties, and 
which the diarrhoea serves to remove. 

The danger arises from complications, as spurious hydrocephalus, or from 
the emaciation and exhaustion, or from its eventuating in inflammation. 

If the rotundity of the figure and firmness of the tissues be preserved, 
showing that alimentation is still sufficient, and no complication arise, the diar- 
rhoea is not as a rule dangerous. In infants that over-nurse and do not vomit 
the surplus milk, the evacuations are sometimes green and frequent, and yet 
fulness of figure is preserved and the development of the body proceeds as 
usual. On the other hand, diarrhoea attended by emaciation or softness or 
flabbiness of the flesh involves danger and requires immediate treatment. 

Treatment. — It is necessary, in order to treat diarrhoea in infancy and 
childhood successfully, to ascertain the cause, and, as far as possible, to 
remove it. It is not till the cause ceases to operate that we can expect a 
satisfactory result from medication. The disease may be temporarily relieved 
by medicine, but it usually returns at once when treatment is omitted, unless 
the patient be removed from the influence of the agencies which produce it. 
These remarks are especially applicable to the diarrhoea of infants. With 
them very generally, when affected with this complaint, there is some fault 
as regards the quantity or quality of food. Attention to this matter will 
show the need of a change of wet-nurse, or, if the infant be spoon-fed, a 
change in the character of its food or in the mode of preparation, or even in 
the quantity given. Sometimes by change in the diet and the adoption of 
hygienic measures the complaint ceases, so as to require no medication. 
Sometimes the temporary abstinence from milk-food, and the employment 
of barley gruel in its place or the use of barley gruel and peptonized milk, 
or, better, barley gruel mixed with the white of an egg, added to a little cold 
water and beaten in a saucer five minutes, suffice to cure the diarrhoea, If 
medicines be needed and the symptoms are not urgent, it is occasionally 
advantageous to commence treatment by the use of one of the milder purga- 



SIMPLE DIARRHCEA. 729 

tives in a small dose. In the in/ant, in whom the dejections are so generally 
acid, an alkaline laxative or a laxative conjoined with an alkali often has a 
good effect as preliminary treatment. Half a teaspoonful to one teaspoonful 
of castor oil or a proportionate dose of calcined magnesia removes any acid 
or irritating snbstance from the intestines, and is followed by a diminution in 
the number of stools. The improvement, however, without subsequent treat- 
ment is usually only for a day or two. A purgative dose of castor oil is 
often given as a domestic remedy in infantile diarrhcea, the beneficial effect 
from it having popularized its use for this purpose. Trousseau usually gave 
Eochelle salts, but this medicine is too severe and dangerous for the treat- 
ment of infantile diarrhcea, especially in warm months. 

If there have been previous constipation and the diarrhcea have just com- 
menced, a purgative is obviously indicated. West says : " Provided there 
be neither much pain nor much tenesmus, and the evacuations, though 
watery, are fecal and contain little mucus and no blood, very small doses of 
the sulphate of magnesia and tincture of rhubarb have seemed to me more 
useful than any other remedy : 

R. Magnesiae sulphatis, £j ; 

Tinct. rhei, 3j ; 

Syr. zingiberis, 3J 5 

Aquae carui, gix. — Misce. 

Dose, 3J three times daily for a child one year old. 

I seldom fail to observe from it a speedy diminution in the frequency of 
the action of the bowels and a return of the natural character of the 
evacuations." 

Since many cases of simple diarrhcea are due to the use of food which 
does not readily digest, but undergoes in part fermentation, the food should 
be carefully selected and prepared according to the directions given in the 
chapters relating to artificial feeding. In cases of fermentation, due often 
to microbic agency, the digestion is very imperfect, and the diarrhcea which 
results is often best treated, so far as medicines are concerned, by the use of 
pepsin and bismuth subnitrate, as ten or fifteen grains of pepsinum sac- 
charatse and bismuth subnitrate given at each feeding. 

In the simple diarrhcea of infants the compound powder of chalk and 
opium is sometimes a good remedy, combining as it does an astringent with 
the opiate and alkali. It may be given in doses of three grains to a child 
one year old every three hours midway between the feedings. The follow- 
ing is a convenient formula for administering substantially the same medi- 
cines in the liquid form : 

R. Tinct. opii deodorat., gtt. xvj ; 

Bismuth, subnitrat., gij ; 

Wyeth's elix. of digestive ferments 

or Fairchild's essence of pepsin, ^ss ; 
Aquae, ^iss. — Misce. 

Shake well, and give one teaspoonful every three hours between the feedings. 

If the patient be not relieved by the opiate, digestive ferment, and bis- 
muth, and by proper regimen, in all probability inflammation of the intes- 
tinal mucous membrane is present. In patients over the age of two or three 
years simple diarrhcea approaches in character that of the adult, and the 
treatment appropriate for the adult is proper in these cases, allowance being- 
made for the difference in age. In infants, in whom this disease, if pro- 
tracted, very soon becomes an undoubted entero-colitis, attended if it be pro- 



730 LOCAL DISEASES. 

tracted by emaciation and weak heart, stimulating digestive agents are often 
required at an early period on account of the prostration and feeble power 
of endurance. 



CHAPTER VIII. 

INTESTINAL CATAKKH OF INFANCY (ENTEKO-COLITIS). 

It is customary with writers to treat of inflammation of the small and 
large intestines in infancy as a single disease, for the following reasons: 
First, the symptoms of colitis at this period of life do not ordinarily differ,, 
in any marked degree, from those of enteritis. The tormina, tenesmus, and 
abdominal tenderness which characterize colitis in childhood and adult life 
are ordinarily lacking or are not appreciable by the observer, and the niuco- 
sanguineous evacuations are oftener absent than present. On account of this 
absence of symptoms Bouchut says : " Dysentery is a very rare disease 
among young children. Its existence might even be denied if it had not 
been observed at the period of some severe epidemics of dysentery." If 
Bouchut refers by the term " dysentery " to the ordinary phenomena of that 
disease, his remark is correct ; but as regards the lesions it is erroneous, for 
colitis is a common infantile malady. Billard, after analyzing eighty cases 
of intestinal inflammation in infants, says : " From this calculation it is 
evidently very difficult to make a correct diagnosis of inflammation of the 
intestinal tube in suckling infants, yet it would seem as if the proper signs 
of enteritis or ileitis were the rapid tympanitis of the abdomen, the diar- 
rhoea, accompanied with vomiting ; while in colitis, diarrhoea alone, without 
tympanitis, is the most frequent." And again : " In consequence of the 
impossibility we have found to exist of tracing with exactitude the series of 
symptoms proper to inflammation of the different portions of the digestive 
tube, we shall content ourselves with presenting an analytical sketch of the 
causes, symptoms, and ordinary course of inflammation of the mucous mem- 
brane of the intestines in general." 

The frequent absence of any pathognomonic symptom or sign by which 
to determine the exact seat of intestinal inflammation in the infant is admitted 
by recent observers as well as Billard. 

The second reason why intestinal inflammation in the infant is described 
as a single disease is, that enteritis and colitis in the majority of cases coexist. 
This will be seen when we come to speak of the anatomical characters. 

In rural districts infantile diarrhoea is not so prevalent and fatal as in 
cities. In the farming sections it does not materially increase the death-rate,, 
and it is therefore not so important a malady as in cities. In cities it largely 
increases the aggregate of deaths. Especially fatal is that form of it which 
is known as the summer epidemic, as is seen by the mortuary records of 
any large city. Thus, in New York City during 1882 the deaths from diar- 
rhoea reported to the Health Board, tabulated in months, were as follows : 

Jan. Feb. Mar. Apr. May. June. July. Aug. Sept. Oct. Nov. Dec. 
Under five vears . .34 32 50 50 72 231 1533 817 362 195 68 35 
Over five years. . . 14 15 14 20 15 19 131 149 84 55 31 24 

It is seen that in 1882 in New York City the deaths from diarrhoea under 
the age of five years were greatly in excess of the number during the whole 
period of life subsequently to that age. 



INTESTINAL CATARRH OF INFANCY. 731 

The following statistics show how great a destruction of life this malady 
causes even under the surveillance of an energetic Health Board ; and before 
this Board was established it was much greater, as I had abundant opportuni- 
ties to observe. The last annual report of the New York Board of Health 
was made in 1875, since which time weekly bulletins have been issued. The 
deaths from diarrhoea at all ages in the last three years in which annual 
reports were issued were as follows : 

1873. 1874. 1875. 

January - - 94 43 46 

February 84 34 52 

March * 93 40 58 

April 114 47 45 

May 95 61 89 

June 220 144 157 

July 1514 1205 1387 

August 967 1007 1012 

September 424 587 608 

October 213 255 185 

November 87 105 57 

December 53 56 50 

In its annual report for 1870 the Board states : ." The mortality from the 
diarrhceal affections amounted to 2789, or 33 per cent, of the total number 
of deaths ; and of these deaths, 95 per cent, occurred in children less than 
five years old, 92 per cent, in children less than two years old, and 67 per 
cent, in those less than a year old." Every year the reports of the Health 
Board furnish similar statistics, but enough have been given to show how 
great a sacrifice of life infantile diarrhoea produces annually in that city. 

What we observe in New York in reference to this disease is true also, to 
a greater or less extent, in other cities of this country and Europe, so far as 
we have reports. Not in every city is there the same proportionate mortality 
from this cause as in New York, but the frequency of infantile diarrhoea and 
the mortality which attends it render it an important disease in, I believe, 
most cities of both continents. In country towns, whether in villages or 
farm-houses, this disease is comparatively unimportant, inasmuch as few cases 
occur in them, and the few that do occur are of mild type, and consequently 
much less fatal than in cities. 

The comparative immunity of rural districts has an important relation, as 
we will see, to the hygienic management of these cases. 

Etiology. — The intestinal catarrh of infants is occasionally produced by 
taking cold. Infants insufficiently protected by clothing and exposed to 
sudden changes of temperature or to currents of air in the apartments 
where they reside, or heedlessly exposed out-doors by careless nurses, some- 
times become affected with diarrhoea, even of a fatal character. They con- 
tract an intestinal inflammation from taking cold, just as other infants may 
contract coryza or bronchitis from the same cause. 

But the most common causes of infantile diarrhoea are, first, the use of 
food which is unsuitable for infantile digestion, and which therefore acts as 
an irritant ; and, secondly, residence in a foul atmosphere, to which we will 
soon call attention, and which largely increases the percentage of deaths in 
our cities during the hot months. Diarrhoea due to taking cold occurs in all 
localities and climates, but it is obviously most common in time of change- 
able weather. That due to the use of unsuitable food and foul air occurs 
for the most part in cities, and much more frequently in the summer season 
than in the cool months, as the above statistics show. Infantile intestinal 
catarrh, however produced, presents nearly the same anatomical characters, 



732 LOCAL DISEASES. 

so that, whatever its etiology, it is proper to describe it as one disease ; but 
that form of it which requires most elucidation, and the causes of which we 
will consider in the following pages, is that produced by impure air and 
improper diet. 

The prevalence and severity of infantile diarrhoea in cities correspond 
closely with the degree of atmospheric heat, as may be inferred from the 
foregoing statistics. In New York this disease begins in the month of May 
— earlier in some years than in others — in a few scattered cases, commonly 
of a mild type. Cases become more and more numerous and severe as the 
weather grows warmer, until July and August, when the diarrhoea attains its 
maximum prevalence and severity. In these two months it is by far the most 
frequent and fatal of all the diseases in the cities. In the middle of Sep- 
tember new patients begin to be less common, and in the latter part of this 
month and subsequently new cases do not occur, unless under unusual cir- 
cumstances which favor the development of this malady. In New York a con- 
siderable number of deaths of infants occur from diarrhoea in October. October 
is not a hot month in our latitude — its average temperature is lower than that 
of May — and yet the mortality from this disease is considerably larger in the 
former than in the latter month. This fact, which seems to show that the 
prevalence of the summer diarrhoea does not correspond with the degree of 
atmospheric heat, is readily explained. The mortality in October, and indeed 
in the latter part of September, is not that of new cases, but is mainly of 
infants, as I have observed every year, who contract the disease in July or 
August or earlier, and linger in a state of emaciation and increasing weak- 
ness till they finally succumb, some even in cool weather. 

The fact is therefore undisputed, and is universally admitted, that the 
summer season, stated in a general way, is the cause of this annually recur- 
ring diarrhoea! epidemic. That atmospheric heat does not in itself cause 
the diarrhoea is evident from the fact that in rural districts there is the same 
intensity of heat as in cities, and yet the summer complaint does not occur. 
The cause must be looked for in the state of the atmosphere engendered by 
heat where unsanitary conditions exist, as in large cities. Moreover, obser- 
vations show that the noxious effluvia with which the air becomes polluted 
under such circumstances constitute or contain the morbific agent. Thus, in 
one of the institutions of this city a few years since, on May 10th, which 
happened to be an unusually warm day for this month, an offensive odor was 
noticed in the wards, which was traced to a large manure heap that was being 
upturned in an adjacent garden. On this day four young children were 
severely attacked by diarrhoea, and one died. Many other examples might 
be cited showing how the foul air of the city during the hot months, when 
animal and vegetable decomposition is most active, causes diarrhoea. Several 
years since, while serving as sanitary inspector for the Citizens' Association in 
one of the city districts, my attention was particularly called to one of the 
streets, in which a house-to-house visitation disclosed the fact that nearly 
every infant between two avenues had diarrhoea, and usually in a severe form, 
not a few dying. The street was compactly built with wooden tenement- 
houses on each side, and contained a dense population, mainly foreigners, poor, 
ignorant, and filthy in their habits. It had no sewer, and the refuse of the 
kitchens and bed-chambers was thrown into the street, where it accumulated 
in heaps. Water trickled down over the sidewalks from the houses into the 
gutters or was thrown out as slops, so that it kept up a constant moisture of 
the refuse matter which covered the street, and promoted the decay of the 
animal and vegetable substances which it contained. The air in the domiciles 
and street under such conditions of impurity was necessarily foul in the 
extreme, and stifling during the hot days and nights of July and August ; 



INTESTINAL CATARRH OF INFANCY. 733 

and it was evidently the important factor in producing the numerous and 
severe diarrhoeal cases which were in these domiciles. 

In another locality, occupied by tripe-dealers and a low class of butchers 
who carried on fat- and bone-boiling at night, the air was so foul after dark 
that the peculiar impurity which tainted it could be distinctly noticed in the 
mouth for a considerable time after a night visit. In the street where these 
nuisances existed and in adjacent streets the summer diarrhoea was very 
prevalent and destructive to human life. Murchison states that 20 out of 25 
boys were affected with purging and vomiting from inhaling the effluvia from 
the contents of an old drain near their school-room. Physicians are familiar 
with a similar fact showing this purgative effect of impure air — that the 
atmosphere of a dissecting-room often causes diarrhoea in those otherwise 
healthy. 

The impurities in the air of a large city are very numerous. Among those 
of a gaseous nature are sulphurous acid, sulphuric acid, sulphuretted hydro- 
gen; various gases of the carbon group, as carbonic acid, carburetted hydrogen, 
and carbonic oxide ; gases of the nitrogen group, as the acetate, sulphide, 
and carbonate of ammonium, nitrous and nitric acids; and at times com- 
pounds of phosphorus and chlorine (Parkes). A theory deserving consider- 
ation is that certain gaseous impurities found in the air form purgative com- 
binations. D. F. Lincoln, in his interesting paper on the atmosphere, in the 
Cyclopaedia of Medicine, writes in regard to sulphuretted hydrogen : '* When 
in the air, freely exposed to the contact of oxygen, it becomes sulphuric acid. 
Sulphide of ammonium in the same circumstances becomes a sulphate, which, 
encountering common salt (chloride of sodium), produces sulphate of sodium 
and chloride of ammonium. The sulphates form a characteristic ingredient 
of the air in manufacturing districts." The sulphates, we know, are for the 
most part purgatives, but whether they or other chemical agents exist in the 
respired air in sufficient quantity to disturb the action of the intestines, 
even where atmospheric impurities are most abundant, is problematical and 
uncertain. 

Again, the solid impurities in the air of a large city are very numerous, 
as any one may observe by viewing in a darkened room a sunbeam which is 
made visible by the numerous particles floating in it. These particles consist 
largely of organic matter, which sometimes has been carried a long distance 
by the wind. The remarkable statement has been made that in the air of 
Berlin organic forms have been found of African production. Ehrenberg 
discovered fragments of insects of various kinds — rhizopods, tardigrades, 
polygastrics, etc. — which, existing in considerable quantity and inhaled in 
hot weather when decomposition and fermentation are most active, may be 
deleterious to the system. Monads, bacteria, vibriones, amorphous dust con- 
taining spores which retain their vitality for months, are among the substances 
found in the air of cities. The well-known hazy appearance, when viewed from 
a distance, of the atmosphere resting over a large city like New York is due 
to the gaseous and solid impurities with which the air is so abundantly sup- 
plied — impurities which assume importance in pathological studies, since 
minute organisms are now believed to cause so many diseases the etiology of 
which has heretofore been obscure. There can be no reasonable doubt, from 
recent investigations, that the deleterious agents which cause the form of 
diarrhoea which we are considering are to a great extent bacteria, which find a 
soil most favorable for their propagation where the air as well as ingesta con- 
tains impurities. In foul air, as in the summer season in the crowded parts 
of the city, and especially where decomposing animal and vegetable matter 
exists, the number of micro-organisms is vastly greater, as different observers 
have remarked, than in salubrious localities. Foul air and unwholesome food 



734 LOCAL DISEASES. 

— food that has begun to undergo decomposition or that digests with difficulty, 
so that part of it ferments — afford the conditions which are eminently favor- 
able for the development of pathogenic as well as non-pathogenic germs. We 
have seen that Booker and Vaughn have found bacteria in diarrhceal stools 
which when isolated by cultivation either kill the animals experimented on 
or cause intestinal catarrh in them, or the toxins produced by the bacteria 
have this effect. The evidence, therefore, is strong that bacteria are the 
chief causal agents of those forms of diarrhoea which originate from foul 
air and unwholesome and indigestible food. 

In those portions of our cities which are occupied by the poor more than 
anywhere else those conditions prevail which render the atmosphere foul and 
unwholesome. One accustomed to the pure air of the country would scarcely 
believe how stifling and poisonous the atmosphere becomes during the hot 
summer days and close summer nights in and around the domiciles in the 
poor quarters of the city. Among the causes of this foul air may be men- 
tioned too dense a population, the occupancy of small rooms by large families, 
rigid economy, and ceaseless endeavor to make ends meet, so that in the 
absorbing interest sanitary requirements are sadly neglected. Adults of such 
families, and children of both sexes as soon as they are old enough, engage 
in laborious and often filthy occupations. Many of them seldom bathe, and 
they often wear for days the same under-garments, foul with perspiration and 
dirt. The intemperate, vicious, and indolent, who always abound in the quar- 
ters of the city poor, are notoriously filthy in their habits and add to the insa- 
lubrity by their presence. Children old enough to be in the streets and adults 
away at their occupations escape to a great extent the evil effects of impure 
air, but the infantile population always suffers severely. 

Every physician who has witnessed the summer diarrhoea of infants is 
aware of the fact that the mode of feeding has much to do with its occur- 
rence. A large proportion of those who each summer fall victims to it 
would doubtless escape if the feeding were exactly proper. In New York 
City facts like the following are of common occurrence in the practice of all 
physicians : Infants under the age of eight months, if bottle-fed, nearly 
always contract diarrhoea, and usually of an obstinate character, during the 
summer months. The younger the infant, the less able is it to digest any 
other food than breast-milk, and the more liable is it therefore to suffer from 
diarrhoea if bottle-fed. In the institutions nearly every bottle-fed infant 
under the age of four or even six months suffers in the hot months from symp- 
toms of indigestion and intestinal catarrh, while the wet-nursed of the same 
ages remain well. Sudden weaning, the sudden substitution of cow's milk 
or an artificially prepared food in place of breast-milk in hot weather, almost 
always produces diarrhoea, often of a severe and fatal nature. Feeding an 
infant in the hot months with indigestible and improper food, as fruits with 
seeds or the ordinary table food prepared in such a way that it overtaxes the 
digestive function of the infant, causes diarrhoea, and sometimes that severe 
form of it which will be described under the term cholera infantum. Many 
obstinate cases of the summer complaint begin to improve under change of 
diet, as by the substitution of one kind of milk for another or the return of 
the infant to the breast after it has been temporarily withdrawn from it. It 
is a common remark in the families of the city poor that the second summer 
is the period of greatest danger to infants. This increased liability of infants 
to contract diarrhoea in the second summer is due to the fact that most infants 
in their second year are table-fed, while in the first year they are wet-nursed. 
Such facts, with which all physicians are familiar, show how important the 
diet is as a factor in causing indigestion and diarrhoea. 

Occasionally, from continued ill-health, the milk of the mother or wet- 



INTESTINAL CATARRH OF INFANCY. 735 

nurse does not agree with the nursling. Examined with the microscope. 
it is found to contain colostrum. Under such circumstances if a healthy 
wet-nurse be employed the diarrhoea ceases. It is very important that any 
woman furnishing breast-milk to an infant should lead a quiet and regular 
life, with regular meals and sleep. R. B. Gilbert l relates striking cases in 
which venereal excesses on the part of wet-nurses were immediately followed 
by fatal diarrhoea in the infants whom they suckled. 

One not a resident would scarcely be able to appreciate the difficulty 
which is experienced in a large city in obtaining proper diet for young chil- 
dren, especially those of such an age that they require milk as the basis of 
their food. Milk from cows stabled in the city or having a limited pastur- 
age near the city, and fed upon a mixture of hay with garden and distillery 
products, the latter often largely predominating, is unsuitable. It is defici- 
ent in nutritive properties, prone to fermentation, and from microscopical and 
chemical examinations which have been made it appears that it often con- 
tains deleterious ingredients. If milk be obtained from distant farms, where 
pasturage is fresh and abundant — and in New York City this is the usual 
source of the supply — considerable time elapses before it is served to cus- 
tomers, so that, particularly in the hot months of July and August, it fre- 
quently has begun to undergo lactic-acid fermentation when the infants 
receive it. That dispensed to families in the morning is the milking of the 
previous morning and evening. The use of this milk in midsummer by 
infants under the age of ten months frequently gives rise to more or less 
diarrhoea. 

The ill-success of feeding with cow's milk has led to the preparation of 
various kinds of food which the shops contain, but no dietetic preparation 
has yet appeared which agrees so well with the digestive function of the 
infant, and is at the same time sufficiently nutritive, as the breast-milk of 
healthy mothers or wet-nurses. 

In New York City improper diet, unaided by the conditions which hot 
weather produces, is a common cause of diarrhoea in young infants, for at all 
seasons we meet with this diarrhoea in infants who are bottle-fed ; but when 
the atmospheric conditions of hot weather and the use of food unsuitable for 
the age of the infant are both present and operative, this diarrhoea so increases 
in frequency and severity that it is proper to designate it the summer epidemic 
of the cities. Several years since, before the New York Foundling Asylum 
was established, the foundlings of New York, more than a thousand annually, 
were taken to the almshouse on Blackwell's Island and consigned to the care 
of pauper-women, who were mostly old, infirm, and filthy in their habits and 
apparel. Their beds, in which the foundlings were also placed alongside of 
them, were seldom clean, not properly aired and washed, and under the beds 
were various garments and utensils which these pauper-women had brought 
with them as their sole property from their miserable abodes in the city. 
With such surroundings the air which these infants breathed day and night 
manifestly contained poisonous emanations, while their diet was equally 
improper, for it was prepared by these women from such milk and farinaceous 
food as were furnished to the almshouse. When assigned to duty in the alms- 
house, this service being at that time a branch of Charity Hospital, I was 
informed that all the foundlings died before the age of two months ; one only 
was pointed out as a curiosity which had been an exception to the rule. The 
disease of which they perished was diarrhoea, and this malady in the summer 
months was especially severe and rapidly fatal. The unpleasant experiences 
in this institution furnished additional evidence, were any wanting, that foul 
air and improper diet are the two important factors in causing the summer 
1 Louisville Med. Journal, Aug. 19, 1882. 



736 LOCAL DISEASES. 

diarrhoea of infants. Since that beneficent charity, the New York Foundling 
Asylum, in East Sixty-eighth street, came into existence, providing pure air 
and, for a considerable proportion of the foundlings, breast-milk, many of 
these waifs have been rescued from death. 

Age. — Age is a predisposing cause of intestinal catarrh, since most cases 
occur under the age of three years. A large majority of the summer diar- 
rhoeas of the cities occur under the age of two years. The following table 
embraces all the cases that came to one of the city dispensaries during my 
service between the months of May and October, inclusive: 

Age. Cases. 

5 months or under 58 

5 months to 12 months 212 

12 months to 18 months 174 

18 months to 24 months . 93 

24 months to 36 months 36 

Total 573 

Dentition. — Statistics show that by far the largest number of cases occur 
during the period of first dentition ; hence the prevalent opinion among fam- 
ilies that dentition causes the diarrhoea. It is the common belief among the 
poor of New York that diarrhoea occurring during dentition is conservative, 
and should not be checked. They believe that an infant cutting its teeth suf- 
fers less, and may be saved from serious illness, if it have frequent stools. 
Every summer I see infants reduced to a state of imminent danger through 
the continuance of diarrhoea during several weeks, nothing having been done 
to check it in consequence of this absurd belief. The progressive loss of flesh 
and strength and wasting of the features do not excite alarm, under the blind- 
ing influence of this theory, till the diarrhoea has continued so long and 
become so severe that it is with difliculty controlled, and the patient is in a 
state of real danger when the physician is first summoned. The following 
statistics, which comprise cases occurring during my service in one of the 
city dispensaries, show the preponderance of cases during the age when dental 
evolution is occurring : 

Cases. 

No teeth and no marked turgescence of gums 47 

Cutting incisors - 106 

Cutting anterior molars 41 

Cutting canines 40 

Cutting last molars , 20 

All the teeth cut 28 

Total 282 

It so happens that the period of dental evolution corresponds with that of 
the most rapid development and the greatest functional activity of the gastric 
and intestinal follicles, and the predisposition which exists to diarrhoeal mala- 
dies at this age must be attributed to this cause rather than to dentition. 

Symptoms. — The intestinal catarrh of infancy commonly begins gradually 
with languor, fretfulness, and slight rise of temperature. The diarrhoea at 
first usually attracts little attention from its mildness. The stools, while they 
are thinner than natural, vary in appearance, being yellow, brown, or green. 
Infants with milk diet usually pass green and acid stools containing particles 
of undigested casein. The tongue in the commencement of the attack is moist 
and covered with a slight fur. At a more advanced stage it may be moist, 
but is often dry, and in dangerous forms of the malady, accompanied by pros- 
tration, the buccal surface is red and the gums more or less swollen and some- 



INTESTINAL CATARRH OF INFANCY. 737 

times ulcerated. Vomiting is common. It may commence simultaneously 
with the diarrhoea, especially when food that is indigestible and irritating to 
the stomach has been given, but more frequently this symptom does not 
appear until the diarrhoea has continued a few days. I preserved memoranda 
of the date when vomiting began in the cases treated in two consecutive 
years, and found that ordinarily it was toward the close of the first week. 
When it is an early and prominent symptom it appears to be due to the 
presence in the stomach of imperfectly digested or fermented and acid food, 
which, when ejected, gives a decidedly acid reaction with appropriate tests. 
It contains coagulated casein and undigested particles of whatever food has 
been given. In many patients the progressive loss of flesh and strength is 
largely due to the indigestion and vomiting, by which the food, which is so 
much required for proper nourishment, is lost. 

Emesis occurring at a late stage of infantile diarrhoea is often due to 
commencing spurious hydrocephalus, which is not an infrequent complica- 
tion, as we will see, of protracted cases. Perhaps when a late symptom it 
may sometimes have an ursemic origin, for the urine is usually quite scanty 
in advanced cases. It seems probable, however, that deleterious effects 
from non-elimination of urea are to a considerable extent prevented by the 
diarrhoea. 

The fecal evacuations may remain nearly uniform in appearance during 
the disease, but in many patients they vary in color and consistence at differ- 
ent periods. In the same case they may be brown and offensive at one time, 
green at another, and again they may contain masses of a putty-like appear- 
ance, the partly-digested casein or altered epithelial cells. The stools some- 
times consist largely of mucus, with or without occasional streaks of blood, 
indicating the predominance of inflammation in the colon. The stools are 
sometimes yellow when passed, but become green on exposure to the air 
from chemical reaction due to admixture with the urine or to the agency of 
the microbe mentioned above that produces green coloring matter. 

The character of the alvine discharges is interesting. In addition to 
undigested casein I have found epithelial cells, single or in clusters (some- 
times regularly arranged as if detached in mass from the villi), fibres of 
meat, crystalline formations, mucus, and occasionally blood, as stated above. 
In one instance I observed an appearance resembling three or four crypts of 
Lieberkuhn united, probably thrown off by ulceration. If the stools are 
green, colored masses of various sizes, but mostly small, are also seen under 
the microscope. 

The pulse is accelerated according to the severity of the attack. The 
heat of the surface is at first generally increased, though but slightly in 
ordinary cases ; but when the vital powers begin to fail from the continuance 
of the diarrhoea, the warmth of the surface diminishes. In advanced cases 
approaching a fatal termination the face and extremities are pallid and cool, 
and the pulse gradually becomes more frequent and feeble. The skin is 
usually dry, and, as already stated, the urinary secretion diminished. In 
severe cases attended by frequent alvine discharges the infant does not pass 
urine oftener than once or twice daily. The imperfect action of the skin 
and kidneys is noteworthy. 

Protracted cases of diarrhoea are frequently complicated by two cuta- 
neous eruptions — erythema extending over the perineum and frequently as 
far as the thighs and lower part of the abdomen, due to the acid and irritat- 
ing character of the stools ; and boils upon the forehead and scalp. The 
latter sometimes extend to the pericranium, and in case of recovery leave 
permanent cicatrices. This furuncular affection of the scalp has seemed to 
me useful in consequence of the external irritation which it causes, since it 
47 



738 LOCAL DISEASES. 

occurs at a time when, on account of the feeble heart's action and languid 
circulation, passive congestion of the vessels of the brain and meninges is 
liable to be present. 

Patients who are weak and wasted in consequence of protracted diarrhoea, 
remaining almost constantly in the recumbent position, often have an occa- 
sional dry cough which continues till the close of life. It is due to hypo- 
static congestion in the lungs, usually limited to the posterior and inferior 
portions of the lobes, extending but a little way into the lungs. It is the 
result of prolonged recumbency with feeble heart's action and feeble pulmo- 
nary circulation. Infants reduced by chronic diseases, lying day after day 
in their cribs, with little movement of their bodies, are very liable to this 
passive congestion of depending portions of their lungs, toward which the 
blood gravitates, and into which but little air enters in consequence of their 
distance and position and the feeble respirations. The hyperseniia which 
results is of a passive character, a venous congestion, and the affected lobules 
have a dusky-red color. This congestion, continuing, soon results in pneu- 
monia of the catarrhal form, subacute and of a low grade, for pulmonary 
lobules in which the blood remains stagnant soon exhibit augmented cell- 
proliferation, perhaps from the irritating effects of the elements of the blood 
now withdrawn from the circulation. 

I have made or procured a considerable number of microscopic examina- 
tions in these cases of hypostatic pneumonia, and the solidification of the 
pulmonary lobules has been found to be due to the exaggerated development 
of the epithelial cells in the alveoli, together with venous congestion. The 
affected lobules, whether in a stage of hypostatic congestion or the more 
advanced stage of hypostatic pneumonia, when examined at the autopsy 
were somewhat softer than in health, of dark color, and many of the lobules 
could be inflated by strong force of the breath ; but in protracted cases the 
alveoli in central parts of the inflamed area resisted insufflation. The lung 
in hypostatic pneumonia, even when it is inflated, still feels firmer between 
the fingers than the normal lung. 

Hypostatic pneumonia is so common in hospitals for infants that some 
physicians whose observations have been chiefly in such institutions have 
almost ignored other forms of pulmonary inflammation. Billard many years 

ago wrote : " The pneumonia of young children is evidently the 

result of stagnation of blood in their lungs. Under these circumstances the 
blood may be regarded as a kind of foreign body." Of all the chronic and 
exhausting diseases of infancy, no one has, according to my observations, 
been so frequently complicated by hypostatic pneumonia as the disease which 
we are considering, although it does not usually give rise to any more promi- 
nent symptom than an occasional cough. Limited to a small and almost 
immovable part of the lung, it does not ordinarily accelerate respiration or 
render it painful, and the cough is also apparently painless. 

When the progressive loss of flesh and strength has continued several 
weeks and the patient is much exhausted, another complication is liable to 
occur, known as spurious hydrocephalus or the hydrocephaloid disease, the 
anatomical characters of which will be described in the proper place. The 
commencement of spurious hydrocephalus is announced by gradually in- 
creasing drowsiness, perhaps preceded by a period of fretfulness. Vomiting 
and rolling the head are occasional early symptoms of this complication. As 
the drowsiness increases the pupils become less sensitive to light than in 
their normal state, and are usually contracted. When the drowsiness becomes 
profound and constant the pupils remain contracted as in sound sleep or in 
opium narcotism. The functional activity of the organs is now also dimin- 
ished, the vomiting ceases, the stools become less frequent, the buccal sur- 



INTESTINAL CATARRH OF INFANCY. 739 

face dry. and the urine scanty, while the pulse is frequent and feeble. 
Spurious hydrocephalus either continues till death or by stimulation the 
patient may emerge from it. When profound the usual result is death. 

Although infantile diarrhoea in its commencement may be promptly 
arrested by proper hygienic and medicinal treatment, if it continue a few 
weeks the anatomical changes which occur are such that recovery, if it take 
place, is necessarily slow and gradual. Improvement is shown by better 
digestion, stools fewer and of better appearance, less frequent vomiting, a 
more cheerful countenance, and the absence of symptoms which indicate a 
complication. 3Iany recover after days of anxious watching and perhaps 
after many fluctuations. 

Death may occur early from a sudden aggravation of symptoms and rapid 
sinking, or the attack may be so violent from the first that the infant quickly 
succumbs ; but more frequently death takes place after a prolonged sickness. 
Little by little the patient loses flesh and strength till a state of marked 
emaciation is reached. The eyes and cheeks are sunken, the bony projections 
of the face, trunk, and limbs become prominent, and the skin lies in wrinkles 
from the wasting. The altered expression of the face makes the patient 
look older than the actual age. The joints in contrast with the wasted 
extremities seem enlarged and the fingers and toes elongated. The stools 
diminish in frequency from diminished peristaltic and vermicular action, and 
vomiting, if previously present, now ceases. A feeble, quick, and scarcely 
appreciable pulse, slow respiration, and diminished inflation of the lungs, 
sightless and contracted pupils, over which the eyelids no longer close, 
announce the near approach of death. The drowsiness increases and the 
limbs become cool, while perhaps the head is hot. The infant no longer has 
the ability to suckle, or if bottle-fed the food placed in the mouth flows back 
or is swallowed with apparent indifference. So low is its vitality that it lies 
pallid and almost motionless for hours or even days before death, and death 
occurs so quietly that the moment of its occurrence is scarcely appreciable. 

Anatomical Characters. — Since the prominent and essential symptoms 
of the disease which we are considering pertain to the digestive apparatus, 
it is evident that the lesions which attend and characterize it are to be found 
in this part of the system. Lesions elsewhere, so far as they are appreciable 
to us. are secondary and not essential. I have witnessed a large number 
of autopsies of infants who have perished from diarrhcea, chiefly in institu- 
tions, and they have been sufficiently marked and uniform to enable us to 
designate it an entero-colitis. Several years since I preserved records of the 
autopsical appearances in the intestinal catarrh of infants, most of them being 
cases of summer diarrhoea. The number aggregated eighty-two. Since then 
I have witnessed many autopsies in institutions in cases of this disease, and 
the lesions observed were similar to those in the eighty-two cases. 

The question may properly be asked, Can inflammatory hyperemia of the 
intestinal mucous membrane be distinguished from simple congestion if there 
be no ulceration and no appreciable thickening of the intestine ? It is pos- 
sible that occasionally I have recorded as inflammatory what was simply a 
congestive lesion, but I do not think I have incorporated a sufficient number 
of such cases to vitiate the statistics. In a large proportion of the cases there 
was evident thickening of the intestinal mucous membrane or other unequivocal 
evidence of inflammation. The following is an analysis of the 82 cases : The 
duodenum and jejunum presented the appearance of inflammatory hyperemia 
in 12 cases: the hyperaemia was usually in patches of variable extent or of 
that form described by the term arborescent. In 51 cases the duodenal and 
jejunal mucous membrane was pale and without any other appearance 
characteristic of catarrh or inflammation. In the remaining 10 eases the 



740 LOCAL DISEASES. 

appearance of the duodenum and jejunum was not recorded, so that it was 
probably normal : on the other hand, in the ileum inflammatory lesions 
were present as a rule. In 49 cases I found the surface of the ileum dis- 
tinctly hypersernic, and in that portion of it nearest the ileo-csecal valve, 
including the valve itself, the inflammation had evidently been the most 
intense, since in this portion the hypersernia and thickening of the mucous 
membrane were most marked. In 16 cases the surface of the ileum appeared 
nearly or quite normal ; in 14 hypersernia in the small intestines in patches, 
streaks, or arborescence was recorded, but the records do not state in which 
division of the intestines they were observed. 

Billard, with other observers, has noticed the frequency and intensity 
of the inflammatory lesions in entero-colitis in the terminal portion of the 
small intestines, and thickening, in many cases, of the ileo-csecal valve, and he 
asks whether the vomiting which is so common and often obstinate in this 
disease may not be sometimes due to obstruction to the passage of fecal 
matter at the valve in consequence of its hyperemia and swelling ; but he 
has not observed any retained fecal matter above it, such as we find in any 
part of the colon, or any other appearance which indicated sufficient obstruc- 
tion to cause symptoms. But it seems not improbable that the reason why 
the inflammatory lesions are more pronounced at and immediately above the 
valve than in other parts of the small intestine is that the fecal matter, so 
commonly acid and irritating in this disease, is somewhat delayed in its 
passage downward at this point. 

Small superficial circular or oval ulcers were observed in the ileum in 
4 cases, in 2 of which they were found also in the lower part of the jejunum. 
In 1 case the records state that ulcers were in the jejunum, but do not men- 
tion whether they were also in the ileum. In 1 case, in which there was much 
thickening of the ileum next to the ileo-csecal valve, many small granulations 
had sprouted up from the submucous connective tissue, so that the mucous 
surface appeared as if studded with small warts. 

Softening of the mucous membrane was also apparent in certain cases. 
The firmness of its attachment to the parts underneath varied considerably 
in different specimens. I was able in cases in which there was considerable 
softening to detach readily the mucous membrane with the nail or handle 
of the scalpel within so short a period after death that it was probable that 
the change of consistence was cadaveric. In some cases the vessels of the 
submucous tissue were injected and this tissue infiltrated. 

In all the cases, except one, lesions were present indicating inflammation 
of the mucous membrane of the colon. In 39 hypersernia, thickening, and 
other signs of inflammation extended over nearly or quite the entire colon ; 
in 14 the colitis was confined to the descending portion entirely or almost 
entirely ; in 28 cases the records state that inflammatory lesions were found 
in the colon, but their exact location is not mentioned. In 18 of the autopsies 
the mucous membrane of the colon was found ulcerated. 

Therefore, according to these statistics — and autopsies which I have wit- 
nessed that are not embraced in them disclosed similar lesions — colitis is 
present, almost without exception, in cases of summer diarrhoea, associated 
with more or less ileitis. The portion of the colon which presents the most 
marked inflammatory lesions is that in and immediately above the sigmoid 
flexure — that portion, therefore, in which any fermenting fecal matter has 
reached its greatest degree of fermentation, and consequently contains the 
most irritating elements, and where, next to the caput coli, it is longest 
delayed in its passage downward. 

The solitary glands of both the large and small intestines and Peyer's 
patches undergo hyperplasia. In cases of short duration and in parts of the 



INTESTINAL CATARRH OF INFANCY. 741 

intestine where the inflammatory action has been mild, the solitary glands 
present a vascular appearance, like the surrounding membrane, and are 
slightly enlarged. The enlargement is most apparent if the intestine be 
viewed by transmitted light, when not only are the glands seen to be 
swollen, but their central dark points are distinct. If a higher grade of 
intestinal catarrh or a catarrh more protracted have occurred, the volume 
of these follicles is so increased that they rise above the common level and 
present a papillary appearance. Peyer's patches are also distinct and punc- 
tate. The enlargement of Peyer's patches, like that of the solitary glands, 
is due to hyperplasia, the elementary cells being largely increased in number. 

The small ulcers which, as we have seen from the above statistics, are 
present in a certain proportion of cases in the mucous membrane of the 
colon, and more rarely in that of the small intestine when the inflammation 
has been protracted and of a severe type, appear to occur in the solitary 
glands and in the mucous membrane surrounding them. While some of 
these glands in a specimen are simply tumefied, others are slightly ulcerated, 
and others still nearly or quite destroyed. The ulcers are usually from one 
to three lines in diameter, circular or oval, with edges slightly raised from 
infiltration. Rarely, I have seen minute coagula of blood in one or more 
ulcers, and I have also observed ulcers which have evidently been larger and 
have partially healed. When ulcers are present they commonly occur in the 
descending colon, or if occurring elsewhere they are most abundant in this 
situation. 

According to my observations, these ulcers are found chiefly in infants 
over the age of six months — during the time, therefore, when there is great- 
est functional activity and most rapid development of the solitary glands. 
Peyer's patches, though frequently prominent and distinct, have not been 
ulcerated in any of the cases observed by me. 

The appendix vermiformis participates in the catarrh when it occurs in 
the caput coli, its mucous membrane being hypersemic and thickened. In 
certain rare cases the inflammation is so intense that a thin film of fibrin is 
exuded in places upon the surface of the colon. It is liable to be overlooked 
or washed away in the examination. The rectum usually presents no inflam- 
matory lesions, or but slight lesions in comparison with those in the colon. 
It remains of the normal pale color, or is but slightly vascular in most 
patients, even when there is almost general colitis. Hence the infrequency 
of tenesmus. If tenesmus be present, probably the rectum participates in 
the inflammation. 

As might be expected from the nature of the disease, the secretion of 
mucus from the intestinal surface is augmented. It is often seen forming a 
layer upon the intestinal surface, and it appears in the stools mixed with epi- 
thelial cells and sometimes with blood and pus. 

The mesenteric glands in cases which have run the most protracted course 
and ended fatally are found more or less enlarged from hyperplasia. They 
are frequently as large as a pea or larger, and of a light color, the color being 
due not only to the hyperplasia, but in part to the anaemia. Occasionally, 
when patients have been much reduced from the long continuance of diar- 
rhoea, and are in a state of marked cachexia before death, we find certain of 
these glands caseous. 

The state of the stomach is interesting, since indigestion and vomiting are 
so commonly present. I have records of the appearance of this organ in 50 
cases, in 42 of which it seemed normal, having the usual pale color and ex- 
hibiting only such changes as occur in the cadaver. In the remaining 17 
cases the stomach was more or less hyperasmic, and in 3 of them points of 
ulceration were observed in the mucous membrane. 



742 LOCAL DISEASES. 

All physicians familiar witli this disease have remarked the frequency of 
stomatitis. In protracted and grave cases it is a common complication. The 
buccal surface in these cases is more vascular than natural, and if the vital 
powers are much reduced superficial ulcerations are not infrequent, oftener 
upon the gums than elsewhere. The gums are frequently spongy, more or 
less swollen, bleeding readily when rubbed or pressed. Thrush is a com- 
mon complication of protracted diarrhoea in infants under the age of three or 
four months, but is infrequent in older infants. Occurring in those over the 
age of six or eight months, it has an unfavorable prognostic significance, indi- 
cating a form of diarrhoea which commonly eventuates in death. 

The belief has long been prevalent in the past that the liver is also in 
fault. The green color of the stools was supposed to be due to vitiated bile. 
But usually in the post-mortem examinations which I have made I have 
found that the green coloration of the fecal matter did not appear at the 
point where the bile enters the intestines, but at some point below the ductus 
communis choledochus, in the jejunum or ileum. The green tinge, at first 
slight, becomes more and more distinct on tracing it downward in the intes- 
tine. The manner in which it is produced has been treated of elsewhere. 

I have notes of the appearance and state of the liver in 32 fatal cases. 
Nothing could be seen in these examinations which indicated any anatomical 
change in this organ that could be attributed to the diarrhceal malady. The 
size and weight of the liver varied considerably in infants of the same age, 
but probably there was no greater difference than usually obtains among 
glandular organs in a state of health. The following was the weight of this 
organ in 20 cases : 

Age. Weight. Age. Weight. 



4 weeks 5 ounces. 

2 months Sh " 

2 " 3| " 

4 " 5 

5 " 6* " 

5 " 9 

7 " 4J " 

7 " 6 

7 " 6£ " 

9 " 8 



10 months 6f ounces. 

13 " 6 

14 " 9 " 

15 " 6 

15 " 7J " 

15 " 9J " 

16 " 6 

19 " U " 

20 " 9£ " 

23 " 15 



In none of these cases did the size, weight, or appearance of this organ seem 
to be different from that in health or in other diseases, except in one in which 
fatty degeneration had occurred, but this was probably due to tuberculosis, 
which was also present. In most of these cases the liver was examined 
microscopically, and the only noteworthy appearance observed was the 
variable amount of oil-globules in the hepatic cells. In some specimens the 
oil-globules were in excess, in others deficient, and in others still they were 
more abundant in one part of the organ than in another. Little importance 
was attached to these differences in the quantity of oily matter. 

Hypostatic congestion of the posterior portions of the lungs, ending if it 
continue in a form of subacute catarrhal pneumonia and giving rise to an 
occasional painless cough, has been described in the preceding pages. The 
character of the cough in connection with the wasting might excite suspicions 
of the presence of tubercles in the lungs ; but tubercles are rare in this dis- 
ease, and when present I should suspect a strong hereditary predisposition. 
They occurred in only 1 of the 82 cases. 

The state of the encephalon in those patients in whom spurious hydro- 
cephalus occurs is interesting. In protracted cases of diarrhoea the brain 
wastes like the body and limbs. In the young infant, in whom the cranial 



INTESTINAL CATARRH OF INFANCY. 743 

bones are still ununited, the occipital and sometimes the frontal bones become 
depressed and overlapped by the parietal, the depression being of course pro- 
portionate to the diminution in size of the encephalon. The cranium becomes 
quite uneven. In other children, with the cranial bones consolidated, serous 
effusion occurs according to the degree of waste, thus preserving the size of 
the encephalon. The effusion is chiefly external to the brain, lying over the 
convolutions from the base to the vertex. Its quantity varies from one or 
two drachms to an ounce or more. Along with this serous effusion, and ante- 
dating it, passive congestion of the cerebral veins and sinuses is also present. 
This congestion is the obvious and necessary result of the feebleness of the 
heart's action and the loss of brain-substance. 

Diagnosis. — In the adult abdominal tenderness is an important diag- 
nostic symptom of intestinal catarrh, but in the infant this symptom is lack- 
ing or is not in general appreciable, so that it does not aid in diagnosis. 
When the diagnosis of the disease is established, the symptoms do not 
usually indicate what part of the intestinal surface is chiefly involved, but 
it may be assumed that it is the lower part of the ileum and the colon. The 
presence of mucus or of mucus tinged with blood in the stools shows the 
predominance of colitis. 

Prognosis. — Although this disease largely increases the death-rate of 
young children, most cases can be cured if proper hygienic and medicinal 
measures be early applied. It is obvious, from what has been stated in the 
foregoing pages, that cholera infantum is the form of this malady which 
involves greatest danger. Except in such cases there is sufficient forewarn- 
ing of a fatal result, for if death occur it is after a lingering sickness, with 
fluctuations and gradual loss of flesh and strength. Patients often recover 
from a state of great prostration and emaciation, provided that no fatal com- 
plications arise. The eyes may be sunken, the skin lie in folds from the 
wasting, the strength may be so exhausted that any other than the recumbent 
position is impossible, and yet the patient may recover by removal to the 
country, by change of weather, or by the use of better diet and remedies. 
Therefore an absolutely unfavorable prognosis should not be made except in 
cases that are complicated or that border on collapse. The most dangerous 
symptoms, except those which indicate commencing or actual collapse, arise 
from the state of the brain. Rolling the head, squinting, feeble action or 
permanent contraction of the pupils, spasmodic or irregular movements of 
the limbs, indicate the near approach of death, as do also coldness of face 
and extremities and inability to swallow. It is obvious also, in making the 
prognosis in ordinary cases, that we should consider the age of the patient, 
and if the diarrhoea be that of the summer season, the state of the weather, 
the time in the summer, whether in the beginning or near its close, and the 
surroundings, especially in reference to the impurity of the air, as well as 
the patient's condition. 

Cholera Infantum, or Choleriform Diarrhoea. 

This is the most severe form of infantile diarrhoea. It receives the name 
which designates it from the violence of its symptoms, which closely resemble 
those of Asiatic cholera. It is, however, quite distinct from that disease. 
It is characterized by frequent stools, vomiting, great elevation of tempera- 
ture, and rapid and great emaciation and loss of strength. It commonly 
occurs under the age of two years. It sometimes begins abruptly, the pre- 
vious health having been good ; in other cases it is preceded by the ordinary 
form of diarrhoea. The stools have been thinner than natural and somewhat 
more frequent, but not such as to excite alarm, when suddenly they become 



744 LOCAL DISEASES. 

more frequent and watery, and the parents are surprised and frightened by 
the rapid sinking and real danger of the infant. 

The first evacuations, unless there have been previous diarrhoea, may 
contain fecal matter, but subsequently they are so thin that they soak into 
the diaper like urine, and in some cases they scarcely produce more of a stain 
than does this secretion. Their odor is peculiar — not fecal, but musty and 
offensive ; occasionally they are almost odorless. Commencing simultaneously 
with the watery evacuations or soon after is another symptom— irritability of 
the stomach, which increases greatly the prostration and danger. Whatever 
drinks are swallowed by the infant are rejected immediately or after a few 
moments, or retching may occur without vomiting. The appetite is lost and 
the thirst is intense. Cold water is taken with avidity, and if the infant 
nurse it eagerly seizes the breast in order to relieve the thirst. The tongue 
is moist at first, and clean or covered with a light fur, pulse accelerated, res- 
piration either natural or somewhat increased in frequency, and the surface 
warm, but its temperature is speedily reduced in severe cases. The internal 
temperature or that of the blood is always very high. In ordinary cases of 
cholera infantum the thermometer introduced into the rectum rises to or 
above 105°, and I have seen it indicate 107°. Although the infant may be 
restless at first, it does not appear to have any abdominal pain or tenderness. 
The restlessness is apparently due to thirst or to that unpleasant sensation 
which the sick feel when the vital powers are rapidly reduced. The urine is 
scanty in proportion to the gravity of the attack, as it ordinarily is when the 
stools are frequent and watery. 

The emaciation and loss of strength are more rapid than in any other dis- 
ease which I can recall to mind, unless in Asiatic cholera. In a few hours 
the parents scarcely recognize in the changed and melancholy aspect of 
the infant any resemblance to the features which it previously exhibited. 
The eyes are sunken, the eyelids and lips are permanently open from the 
feeble contractile power of the muscles which close them, while the loss of the 
fluids from the tissues and the emaciation are such that the bony angles 
become more prominent and the skin in places lies in folds. 

As the disease approaches a fatal termination, which often occurs in two 
or three days, the infant remains quiet, not disturbed even by the flies which 
alight upon its face. The limbs and face become cool, the eyes bleared, 
pupils contracted, and the urine scanty or suppressed. In some instances, 
when the patient is near death, the respiration becomes accelerated, either 
from the effect of the disease upon the respiratory centres or from pulmonary 
congestion resulting from the feeble circulation. As the vital powers fail the 
pulse becomes progressively more feeble, the surface has a clammy coldness, 
the contracted pupils no longer respond to light, and the stupor deepens, from 
which it is impossible to arouse the infant. 

In the more favorable cases cholera infantum is checked before the occur- 
rence of these grave symptoms, and often in cases which are ultimately fatal 
there is not such a speedy termination of the malady as is indicated in the 
above description. The choleriform diarrhoea abates and the case becomes 
one of the ordinary summer complaint. 

Anatomical Characters. — Eilliet and Barthez, who of foreign writers 
treat of cholera infantum at greatest length, describe it under the name of 
gastro-intestinal choleriform catarrh. " The perusal." they remark, " of 
anatomico-pathological descriptions, and especially the study of the facts, 
show that the gastro-intestinal tube in subjects who succumb to this disease 
may be in four different states : (a) either the stomach is softened without 
any lesion of the digestive tube ; (b) or the stomach is softened at the same 
time that the mucous membrane of the intestine, and especially its follicular 



INTESTINAL CATARRH OF INFANCY. 745 

apparatus, is diseased ; (c) or the stomach is healthy, while the follicular 
apparatus or the mucous membrane is diseased ; (d) or, finally, the gastro- 
intestinal tube is not the seat of any lesion appreciable to our senses in the 
present state of our knowledge, or it presents lesions so insignificant that they 
are not sufficient to explain the gravity of the symptoms. 

•• So far. the disease resembles all the catarrhs, but what is special is the 
abundance of serous secretion and the disturbance of the great sympathetic 
nerve. 

•• The serous secretion, which appears to be produced by a perspiration 
(analogous to that of the respiratory passages and of the skin) rather than 
by a follicular secretion, shows, perhaps, that the elimination of substances is 
effected by other organs than the follicles ; perhaps, also, we ought to see a 
proof that the materials to eliminate are not the same as in simple catarrh. 
Upon all these points we are constrained to remain in doubt. We content 
ourselves with pointing out the fact." 1 

On the 1st of August, 1861, I made the autopsy of an infant sixteen 
months old which died of cholera infantum with a sickness of less than one 
day. The examination was made thirty hours after death. Nothing unusual 
was observed in the brain, unless perhaps a little more than the ordinary 
injection of vessels at the vertex. No marked anatomical change was 
observed in the stomach and intestines, except enlargement of the patches of 
Peyer as well as of the solitary and mesenteric glands. Mucous membrane 
pale. In this and the following cases there was apparently slight softening 
of the intestinal mucous membrane, but whether it was pathological or 
cadaveric was uncertain, as the weather was very warm. The liver seemed 
healthy. Examined by the microscope, it was found to contain about the 
normal number of oil-globules. 

The second case was that of an infant seven months old, wet-nursed, who 
died July 26, 1862, after a sickness also of about one day. He was pre- 
viously emaciated, but without any marked ailment. The post-mortem 
examination was made on the 28th. The brain was somewhat softer than 
natural, but otherwise healthy. There was no abnormal vascularity of the 
membranes of the brain, and no serous effusion within the cranium. The 
mucous membrane of the intestines had nearly the normal color throughout, 
but it seemed somewhat thickened and softened ; the solitary glands of the 
colon were prominent. The patches of Peyer were not distinct. 

In the New York Protestant Episcopal Orphan Asylum an infant twenty 
months old, previously healthy, was seized with cholera infantum on the 
24th of June, 1864. The alvine evacuations, as is usual with this disease, 
were frequent and watery and attended by obstinate vomiting. Death 
occurred in slight spasms in thirty-six hours. The exciting cause was prob- 
ably the use of a few currants which were eaten in a cake the day before, 
some of which fruit was contained in the first evacuations. The brain was 
not examined. The only pathological changes which were observed in the 
stomach and intestines were slightly vascular patches in the small intestines 
and an unusual prominence of the solitary glands in the colon. The glands 
resembled small beads imbedded in the mucous membrane. The lungs in 
the above cases were healthy, excepting hypostatic congestion. 

Since the date of these autopsies I have made others in cases which ter- 
minated fatally after a brief duration, and have uniformly found similar 
lesions — to wit, the gastro-intestinal surface either without vascularity or 
scantily vascular in streaks or patches, sometimes presenting a whitish or 
soggy appearance and somewhat softened, while the solitary glands were 
enlarged so as to be prominent upon the surface. In cases which continue 

1 Maladies des Enfants. 



746 LOCAL DISEASES. 

longer evident inflammatory lesions soon appear which are identical with 
those which have already been described in our remarks relating to the ordi- 
nary form of diarrhoea. 

During my term of service in the New York Foundling Asylum in the 
summer of 1884 an infant died after a brief illness with all the symptoms 
of cholera infantum, and the intestines were sent to William H. Welch, now 
of Johns Hopkins Hospital, for microscopic examination. His report was 
as follows : " I found undoubted evidence of acute inflammation. There was 
an increased number of small round cells (leucocytes) in the mucous and 
submucous coats. This accumulation of new cells was most abundant in 
and around the solitary follicles, which were greatly swollen. Clumps of 
lymphoid cells were found extending even a little into the muscular coat. 
The epithelial lining of the intestine was not demonstrable, but this is usu- 
ally the case with post-mortem specimens of human intestine, and justifies 
no inferences as to pathological changes. The glands of Lieberkiihn were 
rich in the so-called goblet-cells, and some of the glands were distended with 
mucus and desquamated epithelium, so as to present sometimes the appear- 
ance of little cysts. This was observed especially in the neighborhood of 
the solitary follicles. The blood-vessels, especially the veins of the sub- 
mucous coat, were abnormally distended with blood. I searched for micro- 
organisms, and found them in abundance upon the free surface of the intes- 
tine, in mucous accumulations there, and also in the mouths of the glands 
of Lieberkiihn. Both rod-shaped and small round bacteria were found. I 
attach no special importance to finding bacteria upon the surface of the 
intestine. The general result of the examination is to confirm the view that 
cholera infantum is characterized by an acute intestinal inflammation." 

Nature. — Cholera infantum appears from its symptoms and lesions to 
be the most severe form of intestinal catarrh to which infants are liable. 
The alvine discharges, to which the rapid prostration is largely due, probably 
consist in part of intestinal secretions, and in part of serum which has trans- 
uded from the capillaries of the intestines. That the intestinal mucous 
membrane sometimes presents a pale appearance at the autopsy of an infant 
who, previously well, has died of cholera infantum after a sickness of twenty- 
four or forty-eight hours, is perhaps due to the great amount of liquid secre- 
tion and transudation in which the inflamed surface is bathed. Moreover, 
it is, I believe, a recognized fact that the hyperaemia of an acutely inflamed 
surface when of short duration frequently disappears in the cadaver, as that 
of scarlet fever and erysipelas. The early hyperplasia of the solitary and 
mesenteric glands, and the hyperemia and thickening of the surface of the 
ileum and colon in those who have survived a few days, afford additional 
proof of the inflammatory character of the malady. 

The opinion has been expressed by certain observers that cholera infan- 
tum is identical with thermic fever or sunstroke. There is indeed a resem- 
blance to thermic fever as regards certain important symptoms. In cholera 
infantum the temperature is from 105° to 108° ; in sunstroke it is also very 
high, often running above 108°. Great heat of head, contracted pupils, 
thin fecal evacuations, embarrassed respiration, scanty urine, and cerebral 
symptoms are common toward the close of cholera infantum, and they are 
the prominent symptoms in sunstroke. Nevertheless, I cannot accept the 
theory which regards these maladies as identical, and which removes cholera 
infantum from the list of intestinal diseases. In cholera infantum the gastro- 
intestinal symptoms always take the precedence, and are, except in advanced 
cases, always more prominent than other symptoms. It does not commence 
as by a stroke, like coup de soleil, but it comes on more gradually, though 
rapidly, and it often supervenes upon a diarrhoea or some error of diet. In 



INTESTINAL CATARRH OF INFANCY. 1\1 

the commencement of cholera infantum the infant is usually not drowsy, 
and is often wide awake and restless from the thirst. Contrast this with the 
alarming stupor of sunstroke. Sunstroke only occurs during the hours of 
excessive heat, but cholera infantum may occur at any hour or in any day 
during the hot weather, provided that there be sufficient dietetic cause. 
Again, intestinal inflammation is not common in sunstroke, while it is the 
common or, as I believe, the essential, lesion of cholera infantum. These 
facts show, in my opinion, that the two maladies are essentially and entirely 
distinct. Nevertheless, cases of apparent sunstroke sometimes occur in the 
infant, and if the bowels are at the same time relaxed the disease may be 
regarded as cholera infantum, and if fatal is usually reported as such to the 
health authorities. Cases of this kind I have occasionally observed or they 
have been reported to me, although they are not common. 

With the exception of the organs of digestion no uniform lesions are 
observed in any of the viscera in cholera infantum, except such as are due to 
change in the quantity and fluidity of the blood and its circulation. Writers 
describe an anaemic appearance of the thoracic and abdominal viscera, and 
occasionally passive congestion of the cerebral vessels. The cerebral symp- 
toms usually present toward the close of life in unfavorable cases of cholera 
infantum are often due to spurious hydrocephalus, which we have described 
above ; but as the urinary secretion is scanty or suppressed, cerebral symp- 
toms may in certain cases be due to uraemia. 

Diagnosis. — This form of the summer diarrhoea is diagnosticated by the 
symptoms, and especially by the frequency and character of the stools. The 
stools have already been described as frequent, often passed with considerable 
force, deficient in fecal matter, and thin, so as to soak into the diaper almost 
like urine. The vomiting, thirst, rapid sinking, and emaciation serve to dis- 
tinguish cholera infantum from other diarrhoea! maladies. 

When Asiatic cholera is prevalent the differential diagnosis between the 
two is difficult if not impossible. 

Prognosis. — Cholera infantum is one of those diseases in regard to which 
physicians often injure their reputation by not giving sufficient notice of the 
danger, or even by expressing a favorable opinion when the case soon after 
ends fatally. A favorable prognosis should seldom be expressed without 
qualification. If the urgent symptoms be relieved, still the disease may con- 
tinue as an ordinary intestinal inflammation, which in hot weather is formid- 
able and often fatal. If the stools become more consistent and less frequent 
without the occurrence of cerebral symptoms, while the limbs are warm and 
the pulse good, we may confidently express the opinion that there is no pres- 
ent danger. 

The duration of true cholera infantum is short. It either ends fatally, 
or it begins soon to abate and ceases, or it continues, and is not to be distin- 
guished in its subsequent course from an attack of summer diarrhoea begin- 
ning in the ordinary manner. 

Treatment op Infantile Diarrhcea. — Obviously, efficient preventive 
measures consist in the removal of infants so far as practicable from the ope- 
ration of the causes which produce the disease. Weaning just before or in 
the hot weather should, if possible, be avoided, and removal to the country 
should be recommended, especially for those who are deprived of breast-milk 
during the age when such nutriment is required. If for any reason it is 
necessary to employ artificial feeding for infants under the age of ten months, 
that food should obviously be used which most closely resembles human milk 
in digestibility and in nutritive properties. 

It is also very important that the infant receive its food in proper quan- 
tity and at proper intervals, for if the mother or nurse in her anxiety to have 



748 LOCAL DISEASES. 

it thrive feed it too often or in too large quantity, the surplus food which it 
cannot digest, if not vomited, undergoes fermentation, and consequently 
becomes irritating to the gastro-intestinal surface. The physician should be 
able to give advice not only in reference to the frequency of feeding, but also 
in regard to the quantity of food which the infant requires at each feeding. 
Correct knowledge and advice in this matter aid in the prevention and cure of 
the diarrhceal maladies of infancy. The reader is referred to the chapters 
relating to the feeding of infants. 

The indications for treatment are : 1st. To provide the best possible food 
which will aiford sufficient nutriment and be easily digested ; 2d. To aid the 
digestive functions of the infant ; 3d. To employ such medicinal agents as can 
be safely given to check the diarrhoea and cure the intestinal catarrh ; 4th. To 
procure fresh air, which is especially needed if the diarrhoea be that of the 
summer season. 

The infant with intestinal catarrh, the prominent symptom of which is 
diarrhoea, is thirsty, and is therefore likely to take more nutriment in the 
liquid form than it requires for its sustenance. If wet-nursed it craves the 
breast, or if weaned it craves the bottle at short intervals. No more nutri- 
ment should be allowed than is required for nutrition, and the thirst may 
be best relieved by a little cold boiled water to which the white of egg is 
added. 

In the dietetic treatment of the summer diarrhoea of the bottle-fed infant, 
in which not only diarrhoea but indigestion and vomiting are prominent symp- 
toms, I at first withhold cow's milk and allow only barley gruel, described in 
a previous page, to which the reader is referred. 

The occasional cases of infantile diarrhoea which result from taking cold 
require to be treated by the use of bland and easily-digested diet, and med- 
icines that are soothing and such as restrain the evacuations and relieve pain ; 
prominent among which remedies are bismuth and an opiate, with the digest- 
ive ferments. 

We have seen that the two factors which produce the microbic diarrhoea 
of infancy, of which the summer epidemic of the cities is the type, are 
improper food and foul air. It is therefore obvious that measures should be 
employed to render the atmosphere in which the infant lives as free as pos- 
sible from noxious effluvia. Cleanliness of the person, of the bedding, and of 
the house in which the patient resides, the prompt removal of all refuse ani- 
mal or vegetable matter, whether within or around the premises, and allowing 
the infant to remain a considerable part of the day in shaded localities where 
the air is pure, as in the parks or suburbs of the city, are important measures. 
In New York great benefit has resulted from the floating hospital which every 
second day during the heated term carries a thousand sick children from the 
stifling air of the tenement-houses down the bay and out to the fresh air of 
the ocean. 

But it is difficult to obtain an atmosphere that is entirely pure in a large 
city with its many sources of insalubrity ; and all physicians of experience 
agree in the propriety of sending infants affected with the summer diarrhoea 
to localities in the country which are free from malaria and sparsely inhab- 
ited, in order that they may obtain the benefits of purer air. Many are the 
instances each summer in New York City of infants removed to the country 
with intestinal inflammation, with features haggard and shrunken, with limbs 
shrivelled and the skin lying in folds, too weak to raise (or at least hold) 
their heads from the pillow, vomiting nearly all the nutriment taken, with 
stools frequent and thin, resulting in great part from molecular disintegration 
of the tissues — presenting, indeed, an appearance seldom observed in any 
other disease except in the last stages of phthisis — and returning in late 



IXTESTIXAL CATARRH OF IXFAXCY. 749 

autumn with the cheerfulness, vigor, and rotundity of health. The localities 
usually preferred by the physicians of this city are the elevated portions of 
New Jersey and Northern Pennsylvania, the Highlands of the Hudson, the 
central and northern parts of New York State, and Northern New England. 
Taken to a salubrious locality and properly fed, the infant soon begins to 
improve if the disease be still recent, unless it be exceptionally severe. If 
the disease have continued several weeks at the time of the removal, little 
benefit may be observed from the country residence until two or more weeks 
have elapsed. 

An infant weakened and wasted by the summer diarrhoea, removed to a 
cool locality in the country, should be warmly dressed and kept indoor when 
the heavy night dew is falling. Patients sometimes become worse from inju- 
dicious exposure of this kind, the intestinal catarrh from which they are suf- 
fering being aggravated by taking cold and perhaps rendered dysenteric. 

Sometimes parents, not noticing the immediate improvement which they 
have been led to expect, return to the city without giving the country fair 
trial, and the life of the infant is then, as a rule, sacrificed. Returned to 
the foul air of the city while the weather is still warm, it sinks rapidly from 
an aggravation of the malady. Occasionally, the change from one rural 
locality to another, like the change from one wet-nurse to another, has a salu- 
tary effect. The infant, although it has recovered, should not be brought 
back while the weather is still warm. One attack of the disease does not 
diminish, but increases, the liability to a second seizure. 

Medicinal Treatment. — Opiates. — It is evident that opiates are less used 
than formerly in the treatment of the microbic diarrhoeas of infancy. A 
proper appreciation of the pathology of these diarrhoeas naturally leads to 
the belief that the opiates are less important as curative agents than they 
were formerly supposed to be. Opiates diminish the peristalsis and the num- 
ber of stools, but they do not destroy the microbes or the ptomaines. Their 
use should, I think, be limited to cases of restlessness, of tenesmus, and of 
frequent watery stools. They may be useful in controlling symptoms till 
other remedies have time to act. One drop of laudanum or fifteen drops 
of paregoric may be given to an infant of ten months and repeated in three 
hours. I prefer paregoric to any other opiate in the treatment of the sum- 
mer diarrhoeas of infancy, since they are attended by marked prostration, and 
this agent is highly stimulating, from the camphor which it contains. Fret- 
fulness without diarrhoea is, as a rule, best relieved by one of the bromides. 

Antiseptics. — Although the pathology of microbic diarrhoea suggests the 
use of antiseptics, my observations have not been favorable to the use of 
salol, naphthaline, or corrosive sublimate. They have seemed to me to do 
more harm than good. Guaita employs sodium benzoate. He administers 
in twenty -four hours one drachm or a drachm and a half in three ounces of 
water, with, it is stated, good results. 1 The antiseptic which is more largely 
used than any other, and which more than any other has the confidence of 
the profession — and justly so — is the subnitrate of bismuth. It undergoes 
a chemical change in the stomach and intestines, becoming a bismuth sulphide 
and causing dark stools. It may be combined with pepsin, in doses of six 
to eight grains for an infant of six months. 

Irrigation of the Stomach. — Physicians of experience in New York and 
elsewhere recommend irrigation of the stomach with warm water in the 
treatment of malnutrition and gastro-intestinal catarrh. It removes from the 
stomach thick curds that digest with .difficulty, as well as other aliment that 
may be undergoing gastric digestion. It has not, perhaps, been sufficiently 
employed to determine its full value, but from what I have seen of its effects 
1 X. Y. Med. Record, May 31, 1884. 



750 LOCAL DISEASES. 

I am not able to recommend it. The nutriment should be given so prepared 
and with such aids to digestion that the heavy casein curds do not form in 
the stomach. Moreover, the gastric juice is the one of the digestive fer- 
ments that is especially destructive to microbes, so that it is needed in the 
stomach for its germicide as well as digestive action. We have seen from 
the observations of Dr. Max Einhart that after two hours the stomach 
digestion of properly prepared milk or milk and barley gruel is completed 
and the stomach in a state to receive more food. For these reasons irriga- 
tion of the stomach, habitually practised even in cases of indigestion or 
catarrh, seems to me more likely to be injurious than beneficial. On the 
other hand, when the stools are fermenting and imperfectly digested, and are 
accompanied by tenesmus, irrigation of the rectum with a pint of hot water 
to which one teaspoonful of acid boraci and one of bismuth nitrate are added 
frequently gives considerable relief. 

Alkalies. — Acids, especially the lactic and butyric products of faulty 
digestion, often collect in the stomach and intestines. These acids, which are 
active irritants, should be neutralized, while we endeavor to prevent their 
production by improving the diet and aiding the digestion. In a few days 
the inflammatory irritation of the mucous follicles causes an exaggerated 
secretion of mucus, which is alkaline, and which neutralizes the acids to a 
considerable extent. It is especially useful when the infant has acid vomit- 
ing and acid stools. Lime-water, the sodium bicarbonate, and the various 
preparations of chalk are the antacids which may be employed to neutralize 
the acids, given midway between the nursings or feedings. An alkali is 
incompatible with pepsin, and, as pepsin preparations are needed to assist 
digestion, they should not be given at the same time with the alkali. 

Astringents. — The vegetable astringents were formerly much used in the 
treatment of the diarrhoeal diseases of infancy, but they are now seldom pre- 
scribed for these cases. Even the mineral astringents, acetate of lead and 
nitrate of silver, have gone out of use in the treatment of the infantile diar- 
rhoeas. The pepsin preparations and bismuth have taken their place. 

Stimulants. — The diarrhoea, if severe, soon produces symptoms of pros- 
tration or heart failure, so that alcoholic stimulation is needed. Brandy or 
whiskey is the best stimulant in this disease : from ten to twenty-five drops, 
according to the age, may be given every second hour. 

Occasionally it is proper to commence the treatment by the employment 
of some gentle purgative, especially when the diarrhoea begins abruptly after 
the use of irritating and indigestible food. A single dose of castor oil or 
syrup of rhubarb, or the two mixed, will remove the irritating substance, and 
afterward remedies designed to control the disease can be more successfully 
employed. 

Some physicians of large experience, as Prof. Henoch of Berlin, recom- 
mend small doses of calomel, as a twelfth or twentieth of a grain, three or 
four times daily. If it be useful, it probably acts as a germicide, but we 
have, it seems to me, more efficient and safer remedies. 

It is very important in the treatment of the summer diarrhoea to aid 
digestion while we employ an antiseptic, and the following are formulae 
which I have employed with apparently the best results : 

R. Acidi hydrochlorici dil., ^xvj ; 

Pepsini puri, in lamellis, £j ; 

Bismuthi subnitrat., ^ij ; 

Syrupi, f%ij ; 

Aquae, fspriv. — Misce. 

Shake bottle. Give one teaspoonful before each feeding or nursing to an infant 
of ten months ; half a teaspoonful to an infant of five months. 



INTESTINAL CATARRH OF INFANCY. 751 

R . Pepsini saccharati, ^i-ij ; 

Bismutbi subnitrat., 313. — Misce. 

Divide in chart No. xii. 
Give one powder before each nursing or feeding to an infant of ten months. 

R . Pepsini pari, in lamellis, 3j ; 

Bismutbi subnitrat. , 5ss ; 

Yini pepsini, N. F. , ^ss ; 

Aquas destillat., 3iiiss. — Misce. 

Shake bottle. Give one teaspoonful before each feeding to an infant at or above 
the age of six months ; half a teaspoonful between the ages of two and six 
months. 

R. Pepsini puri, in lamellis, £j ; 

Bismutbi subnitrat., 3SS. — Misce. 

Give as much as goes on a ten-cent piece or a five-cent nickel piece before each 
nursing or feeding. 

If the diarrhoea and vomiting have ceased, but the digestion be slow and 
incomplete, the following prescriptions will be found useful : 

R. Bismuth, subnitrat., ^ij ; 

Fairchild' s essence of pepsin or Wyeth' s > f z • . 

elixir of digestive ferments, j ^ 3J > 

Aqua? destillat., ^ij. — Misce. 

Shake bottle. Give one teaspoonful every two hours. 

R. Pepsini puri, in lamellis, gj ; 

Vini pepsini, N. F., Jss ; 

Aquse destillat., ^iiiss. — Misce. 

Give half a teaspoonful to one teaspoonful, according to the age, before each 
feeding. 

If cerebral symptoms appear, as rolling the head, drowsiness, etc., indi- 
cating the commencement of spurious hydrocephalus, an alcoholic stimulant, 
as whiskey or brandy, is required ; and although there may be, at times, great 
restlessness, explicit and positive directions should be given to withhold 
opiates if they have been previously employed. One of the bromides, with 
an alcoholic stimulant or the aniseed cordial of the National Formulary, to 
allay restlessness, would be the proper remedy in addition to bismuth and 
pepsin if symptoms of heart failure or spurious hydrocephalus occur. 

External Treatment. — In the gastrointestinal catarrh of the cool months, 
produced by exposure to cold, light and mildly stimulating applications over 
the abdomen are sometimes useful, as a light poultice of flaxseed to which 
one-sixteenth or one-twentieth part of mustard is added, or a poultice of 
flaxseed the under surface of which is covered with 1 part of oil of cloves 
and 8 parts of camphorated oil. But in those forms of gastrointestinal 
catarrh due to improper feeding or insanitary conditions, and having a bac- 
terial origin, external measures are commonly useless, and in the summer 
months they might do injury by increasing the warmth. 



752 LOCAL DISEASES. 

CHAPTER IX. 

EXTEKITIS AND COLITIS IX CHILDHOOD. 

Intestinal inflammation in childhood differs materially from the form 
or type which it commonly presents in infancy. Its causes, symptoms, and 
extent vary in important particulars in the two periods. In childhood there 
is not ordinarily such extensive inflammation of the mucous membrane of the 
intestines as we have seen is present in the majority of cases in infancy, and 
it may therefore be properly treated as two diseases, according to the seat 
of the morbid process — to wit, enteritis and colitis. Both these affections in 
childhood resemble so closely the form which they exhibit in adult life that 
no extended description is needed in this connection. 

Causes. — A main cause is sudden reduction of temperature by exposure 
to cold or to currents of air, which checks perspiration and causes determina- 
tion of blood from the surface to the viscera. These inflammations are also 
caused sometimes by irritating substances in the intestines. I have known 
fecal accumulations, and even rarely worms, to produce severe dysentery in 
the child, accompanied by the characteristic tenesmus and muco-sanguineous 
stools, and ceasing as soon as the offending substances were expelled. The 
use of unripe or stale vegetables, if there be a strong predisposition to 
mucous inflammation, may be a sufficient cause, and some of the most dan- 
gerous cases are due to the accumulation in the intestines of seeds and the 
parenchyma of fruits. But the most common cause is that mentioned — to 
wit. sudden exposure to cold when the body is heated, a danger to which 
children are especially liable on account of the easy disturbance of the cir- 
culatory system in them, and their heedless exposure of themselves unless 
incessantly watched. Enteritis and colitis are also frequently secondary dis- 
eases occurring in childhood as complications or sequelae of the eruptive 
fevers, especially measles. 

Symptoms. — The alvine discharges in enteritis and colitis in childhood are 
such as occur in these diseases at a more advanced age. In enteritis they 
are thin and of the natural color, or occasionally green ; in colitis they are 
more consistent than in enteritis and are largely muco-sanguineous. Some- 
times in enteritis, if the inflammation be not intense, the diarrhoea is slow in 
appearing, or it may be slight, so as not to attract special attention. The 
disease may then resemble remittent fever, for which it is at times mistaken. 
The upper part of the small intestines is less frequently affected than the 
lower. If there be duodenitis, the flow of bile is occasionally impeded from 
tumefaction of the mouth of the common bile-duct, and the icteric hue 
appears. In both enteritis and colitis there is abdominal tenderness, with 
more or less constant pain if the disease be severe, and in colitis tormina and 
tenesmus. The pulse is accelerated, the heat of surface augmented, the face 
flushed and, except in mild cases, expressive of pain. In many children at 
the commencement of the inflammation the nervous system is profoundly 
affected, as indicated by headache, stupor, twitching of the limbs, and some- 
times by convulsions. The chief danger at the commencement of the dis- 
ease is, indeed, from this source. Sometimes irritability of the stomach 
occurs and the food is rejected, though much less frequently than in the 
intestinal inflammation of infancy. Anorexia and thirst are common symp- 
toms. If the inflammation continue, there is soon perceptible emaciation, 
with loss of strength. The eyes become hollow, the face pallid, and the 
surface cool. Death may occur at an early period, the vital powers succumb- 



EXTEBITIS AND COLITIS IN CHILDHOOD. 753 

ing from the intensity of the inflammation. In other cases the acute dis- 
ease ends in a subacute or chronic inflammation ; the patient becomes grad- 
ually more reduced, till he dies in a state of extreme emaciation, such as we 
often observe in the entero-colitis of infancy ; or from this state he may 
recover by degrees, though perhaps with an irritable state of the bowels, 
which continues for months. In a majority of cases, however, enteritis and 
colitis in childhood, if properly treated, soon begin to yield, and they termi- 
nate favorably in one or two weeks. 

Diagnosis. — It is not difficult to determine the existence of the inflam- 
mation. This is indicated by the fever, abdominal tenderness, and the relaxed 
state of the bowels. Whether the disease be enteritis or colitis is determined 
by the character of the stools, the seat of the tenderness, and the presence or 
absence of tenesmus. 

Prognosis. — It has been stated above that enteritis and colitis in chil- 
dren commonly terminate favorably. The result depends not only on the 
extent and severity of the inflammation, but the constitution and previous 
health. The inflammation is more serious when secondary than when pri- 
mary. Extensive and great tenderness of the abdomen, features pallid, anx- 
ious, and expressive of suffering, pulse frequent and feeble, should excite the 
most serious apprehensions. Frequent vomiting also denotes a grave form 
of the disease. Stupor, and especially convulsive movements, show that the 
nervous centres are affected, and should make us guarded in the prognosis. 
Improvement in the disease on which to base a favorable prediction is appa- 
rent in the diminution of the tenderness, improvement in the pulse and 
character of the stools, a more cheerful countenance, and less disrelish of 
food. 

Treatment. — This should be similar to that employed for the adult. 
In enteritis at the commencement of the disease, if there be reason to sus- 
pect the presence of any irritating substance in the intestines, and ordi- 
narily in colitis, it is advisable to commence treatment by the use of some 
simple evacuant, like castor oil. After this our reliance, so far as internal 
treatment is concerned, must be mainly on opiates and antiphlogistic medi- 
cines. One of the best remedies of this class is the Dover's powder, which 
may be given to a child five years old in doses of three grains every three 
hours. A corresponding dose of any of the other opiates may be given, but 
with less sudorific effect. In colitis the occasional administration of a laxa- 
tive should not be neglected if the stools be entirely or mainly muco-sanguin- 
eous. It should be employed so as to prevent accumulation of fecal 
matters in the colon which would serve as an irritant and increase the 
inflammation. The dose should be small, merely sufficient to produce fecal 
evacuation, and repeated as required, daily or less frequently. The laxatives 
commonly preferred are magnesia, rhubarb, or castor oil. The physician 
may prescribe an opiate mixture containing sufficient of the laxative to have 
the effect desired, though ordinarily it is better to prescribe the two sepa- 
rately, so that the laxative can be given or withheld according to circum- 
stances, while the opiate is continued more regularly. Except that there be 
some irritating substance which requires removal, the effect of laxatives is 
injurious instead of beneficial. Instead of a laxative given by the mouth, 
the use of a clyster of glycerin and sweet oil in tepid water is often prefer- 
able. The following prescriptions may be employed for a child of five 
years : 

R. Pulv. opii, gr. v; 

Bismuth, subnitrat., gij. — Misce. 

Divid. in pulveres No. xx. Give one powder every two to four hours. 

48 



754 LOCAL DISEASES. 

R. Pulv. ipecac, comp., gj ; 

Bismuth, subnitrat., ^ij. — Misce. 

Divid. in pulveres No. xxiv. Give one powder as above. 

R . Tine, opii deodorat., ^ss ; 

Bismuth, subnitrat., £ij ; 

Aq. menth. piperit., 
Syr. zingiberis, da. ^j. — Misce. 

Shake bottle. Give one teaspoonful from two to four hours. 

The local treatment which is found most beneficial consists in the use of 
emollient applications covered with oil-silk, and made sufficiently irritating 
by mustard or otherwise to cause constant redness. 

The diet should be bland and unirritating. In the first stage of the 
inflammation rice- or barley-water or arrowroot boiled in water and similar 
drinks should constitute the main diet. When the active inflammation has 
abated, and at any period of the disease if there be a tendency to prostra- 
tion, more nourishing food should be given. Milk and animal broths may 
then be allowed. In cases which are protracted or attended with symptoms 
of exhaustion alcoholic stimulants are required. 



CHAPTER X. 

CONSTIPATION. 

The gastro-intestinal portion of the digestive apparatus has a double 
function. First, it receives and retains the food during the process of diges- 
tion ; it furnishes the most important of the liquids by which digestion is 
effected ; and it absorbs those products of digestion which are required for the 
nutrition of the body, while it serves as a barrier against the admission of 
refuse matter. Secondly, it has an excretory function, so that a large part 
of the waste and noxious products of the system are eliminated from its 
surface. Having, therefore, a relation so close and fundamental to the gen- 
eral nutrition, it is necessary, for the normal activity of the organs and the 
maintenance of health, that its functions be regularly and fully performed. 
But retention of fecal matter beyond the normal period is one of the most 
common ailments both in infancy and childhood, and occasionally it consti- 
tutes a grave disease. The reader is referred to page 130 for remarks relating 
to constipation of the newly-born. 

Constipation is of two kinds — namely, symptomatic and idiopathic. 

Symptomatic Constipation. — Causes. — Many of these are obstructive. 
The more common of them are the following : (a) Congenital stenosis, or 
occlusion of the anus or rectum. The anus is not formed or it terminates 
in a cul-de-sac, while the lower end of the large intestine forms another 
cul-de-sac. These two cul-de-sacs, lying opposite to each other, one look- 
ing upward and the other downward, may be separated from each other by a 
small interspace, a fibrous septum, so that relief can be obtained by a punc- 
ture or incision, or they may be widely separated, so that there is no possible 
mode of relief, and death is inevitable unless the fecal matter escape through 
a congenital fistulous passage upon one of the adjacent mucous surfaces ; 
which mode of relief was present in 40 per cent, of the cases of this 
obstruction collected by Leichtenstern. Exceptionally, this malformation 



COXSTIPATION. 755 

occurs in the sigmoid flexure, while the rectum is normal. The stenosis, if 
slight, may produce little delay in the evacuations, except when hardened 
masses or coarse, indigestible substances descend upon it, and it may there- 
fore, with careful selection of diet, cause little inconvenience for a length- 
ened period, while much stenosis causes early obstructive symptoms. 
Rarely the stenosis is at the ileo-cgecal orifice. (See page 130.) 
(6) Intestinal Displacements. — These produce obstructions of a very pain- 
ful and dangerous kind. Intussusception and external hernia are too well 
known to require description. Both are likely to produce complete obstruc- 
tion if not soon relieved, but there are cases of intussusception in children 
in which the displaced intestine remains pervious, and the evacuations occur 
with more or less regularity ; and the same is true of one form of hernia — 
namely, the congenital — which, although painful, seldom produces serious 
obstruction. 

Painful and dangerous occlusion and consequent arrest of alvine evac- 
uations occasionally result from the imprisonment of a loop of intestine in an 
opening, usually congenital, in the mesentery or diaphragm, or from the 
knotting of one portion of intestine with another, as described by Leichten- 
stern, or again from the twisting of the intestine. Epstein and Soyka * relate 
the case of a new-born infant that died in the second week after birth with 
symptoms of obstruction. At the autopsy a portion of the small intestine 
with its mesentery was found twisted upon its axis from right to left, without 
any marked evidence of inflammation. 

(c) Substances which have been swallowed or substances whose nuclei 
have been swallowed, and which consist of a deposit of carbonate and phos- 
phate of lime, or substances which have been produced entirely in the sys- 
tem, and which, lodged in narrow parts of the intestine, cause obstruction. 
Such substances, some of which occur most frequently in children and others 
in elderly people, produce acute constipation. Indigestible matter contained 
in the food, as seeds or the parenchymatous portions of fruits, occasionally 
collects in considerable quantity and obstructs the intestine. A large gall- 
stone, having escaped from the common bile-duct, sometimes lodges in the 
intestine, either at the ileo-csecal valve or more rarely at some other point, 
and retards the passage of fecal matter. But this seldom occurs in children. 
In one instance, and in only one, have I known obstinate constipation to be 
produced by worms. The patient was a girl of about four years, in whom 
constipation came on suddenly, and was accompanied by distention of abdo- 
men and great suffering. This continued nearly one week, when a mass of 
intertwined round-worms was expelled, with immediate relief. The records 
of medicine also contain cases in which neoplasms, growing from the coats 
of the intestines internally, have attained such a size as to retard the evac- 
uations. 

(d) Abscesses and tumors, especially when occurring in the pelvis, also 
sometimes cause constipation by pressing upon the intestine and obstructing 
or narrowing the passage through it. Thus, in 1868, Mr. Thomas Smith 
related to the London Pathological Society the case of an infant, aged four- 
teen months, in whom both alvine and urinary evacuations were retarded by 
a cancerous tumor growing between the rectum and bladder, and ending fatally 
in three months after the occurrence of the first symptoms. 

(e) Peritonitis, during its continuance, is known to constipate the bowels. 
It is supposed that inflammatory cedema occurs around the muscular fibres 
of the middle coat, by which their contractility is impaired. Hence the lax 
state, the meteorism, and inaction of the intestines in this disease. When 
the peritonitis abates the normal action is restored, and the evacuations occur 

1 Centralb. f. d. med. Wissensch., April 24, 1879. 



756 LOCAL DISEASES. 

regularly if the free surface of the peritoneum have undergone no unfavor- 
able change. But, unfortunately, peritonitis often produces more lasting 
injury, so as to interfere seriously with the intestinal movements and produce 
an habitually torpid state of the bowels. This occurs from adventitious 
bands of inflammatory origin which lie across the intestines, compressing 
them at the points of contact and restraining their movements, and from 
adhesion of the intestinal loops. 

The most marked cases which I have observed of this were children who 
had had tubercular peritonitis. Interesting examples of constipation from 
this cause might be related. 

Occasionally a false band, the result of peritonitis, lies across the intestines, 
without restraining their movements and producing no marked symptoms, 
and probably no symptoms at all, until a loop happens to pass underneath 
it, when, if not soon released, it is liable to become strangulated, with com- 
plete obstruction to the passage of fecal matter. This displacement might 
properly be classified with the internal hernias described above. In my own 
person at the age of twelve years such an accident occurred about two months 
after the peritonitis. Upon the abatement of the inflammation a sensation of 
traction had been noticed in the umbilical region almost daily during exercise, 
and the displacement was indicated by the extreme pain which characterizes 
such cases, and which ceased suddenly when the parts were released after 
about eighteen hours. 

(/) While it is important that the diet and glandular secretions should 
be such that the feculent matter may have proper consistence for easy pro- 
pulsion along the intestinal tube, the important agent by which alvine 
evacuations are effected is obviously muscular contraction. The muscular 
fibres of the intestines produce the vermicular and peristaltic movements 
by which excrement is carried forward, and the abdominal muscles by 
their powerful contraction are the chief agents of expulsion. Now, any 
pathological state which impairs the innervation of these muscles or renders 
it abnormal, destroying the proper balance between " exciting and inhibiting 
impulses," is likely to cause constipation. Hence meningitis, myelitis, and 
certain other diseases of the cerebro-spinal axis, rachitis, general weakness, 
etc., are commonly attended by a sluggish state of the intestines. 

Idiopathic Constipation. — Causes. — These are quite numerous. The 
more prominent of them are the following : First, too little liquid in the 
excrement, so that it is too firm for ready evacuation. There may be too 
little liquid taken in the ingesta or too scanty secretion of the liquids which 
mix with the food, as those of the pancreas, liver, and mucous follicles, or 
there may be too great an absorption of liquid through the coats of the 
intestines, and too active an excretion of water from the skin, kidneys, or 
lung. The firmer the fecal matter the greater the tendency to constipation. 
Those who lose a large amount of water, as in diabetes, night-sweats, or from 
occupations which expose to heat or from residence in a hot climate, are 
especially liable to constipation, except as the loss of liquid is compensated 
by an increased amount of drink. 

The character of the food, apart from the amount of liquid which it con- 
tains, obviously has a marked influence upon the consistence and frequency 
of the stools. Occasionally, the intestines act sluggishly from insufficiency 
of food. Thus, the infant sometimes hangs an unusually long time on the 
breast, and the mother or wet-nurse believes it to be a hearty nurser, when 
there is really a deficiency of milk, and the stools are scanty and infrequent 
from lack of material. Again, constipation is not uncommon in infants who 
nurse heartily and seem to obtain a sufficient quantity of milk, and the cause 
of it is not in the state of the digestive organs, but in the milk. We find 



COXSTIPA TIOK Ibl 

that now and then breast -milk has a constipating effect, although we discover 
nothing to cause this result in the mother's diet or health. The comparison 
of ordinary milk with colostrum may furnish a clew to the explanation. 
Colostrum is known to be more laxative than ordinary milk, and it differs 
from it chemically in containing more butter, sugar, and salts. Hence the 
theory seems plausible that when breast-milk is constipating these elements 
occur in less than the normal quantity. And we shall see hereafter that 
treatment suggested by this theory obviates the constipation. 

The use of a diet which consists chiefly of assimilable substances, as 
animal food, and from which, after the digestive process, little coarse and 
stimulating residuum remains, is obviously liable to produce a sluggish state 
of the bowels. On the other hand, coarse food, as fruits with their seeds, 
coarsely-ground meal, etc., which stimulates the peristaltic action and the 
secretions, increases the number and frequency of the alvine discharges. 

Habit also exerts a decided influence upon defecation. One who, for 
whatever reason, neglects or resists the desire for a stool soon becomes less 
conscious of the daily recurring need and establishes a constipated habit. 
Constipation is more liable to occur in those who lead a quiet life than in 
those who are active. A constipated habit is established in many school- 
children by neglecting or repressing the desire for a stool during school- 
hours. 

But there are cases in which there seems to be a constitutional tendency 
to constipation — a tendency quite independent of the usual conditions. Thus 
I have met children who were bright and active, free from obstruction or 
disease which might retard the evacuations, apparently far from having 
sluggish muscular contractility, and, so far as I could see, with proper diet, 
and yet with defecation, except as it was produced by measures employed, 
occurring no oftener than each second, third, or fourth day. 

But it must be borne in mind that what is constipation in one child may 
not be in another, for occasionally one does well with only one evacuation 
every second or third day, while a large majority require daily defecation in 
order to the maintenance of perfect health. 

In the adult the sacculi or pouches which occur in the walls of the colon, 
produced by contraction of the longitudinal bands acting at right angles to 
the direction of the circular fibres, and consisting of the internal and exter- 
nal tunics without the muscular, become the receptacles for fecal matter in 
those who are constipated, and obviously tend to increase the constipation. 
In children these sacculi are much less developed relatively, and in young- 
infants, whose intestines lack the longitudinal bands, are absent, so that this 
anatomical condition, by which the passage of fecal matter is delayed, is 
unimportant as a cause of constipation in the young. 

On page 131 we have stated that Gautier of Geneva, Switzerland, has 
called attention to an anal fissure as a cause of constipation in the newly- 
born and in older children. The constipation occurs from the endeavor to 
resist defecation on account of the pain. 

We have also remarked on page 131 that constipation has a tendency to 
perpetuate itself, since retained feculent matter becomes more consistent and 
firmer, and the contractile power of the muscular tunic becomes weakened 
by long distention. Obviously, also, an abnormal length of the large intes- 
tine, so that it doubles on itself, whether congenital or the result of con- 
stipation, and a malposition which diminishes the space occupied by the colon, 
and therefore increases its flexures, have a tendency to produce constipation. 

Symptoms. — When there is a mechanical cause which retards the pas- 
sage of fecal matter the acuteness of symptoms and the suffering are gen- 
erally proportionate to the degree of obstruction. Symptomatic constipa- 



758 LOCAL DISEASES. 

tion occurring in an obstructive disease, whether adhesions, peritoneal bands, 
intussusception, knots or twisting of the intestine, incarceration in a false 
passage, or from biliary or intestinal stones or fecal masses, is attended by 
severe symptoms, such as intense colicky pain, vomiting, loss of appetite, 
and rapid prostration. The ingesta accumulate above the point of obstruc- 
tion, producing distention of the intestine with fecal matter and gas, while 
below the point of obstruction the intestine is soon empty. The symptoms 
indeed have the severity and the state involves the danger present in ordinary 
strangulated hernia, while, from being internal, and therefore less accessible 
for treatment, the danger is even greater. If the intestinal tract be narrowed, 
whether by a false ligament, the result of an old peritonitis, or other cause, 
and there be still perviousness, so that excrementitious matter passes by the 
obstruction, though slowly and with more or less difficulty, the patient may 
be comparatively comfortable if the food be such that no hard masses 
remain ; but according to the degree of stenosis and the amount and coarse- 
ness of the fecal matter symptoms occur referable to the obstruction. If the 
excrement be propelled with difficulty through the narrowed part, the mus- 
cular coat above the obstruction gradually becomes more developed from 
hypertrophy of the muscular fibres, just as the heart enlarges from obstruc- 
tive disease of its valves, while below the obstruction the intestine atrophies 
and its calibre diminishes from disuse. Colicky pains, accumulation of fecal 
matter above the obstruction, distention of abdomen, eructation of gas, vom- 
iting, impaired appetite, and consequent decline of the general health, are 
common results. There is constant danger in these cases that the narrow 
passage may become obstructed by fecal matter if it happen to contain hard 
masses or coarse, indigestible substances. The gravest form of constipation 
is obviously that due to mechanical agencies which act as obstacles, but as 
the obstacles are numerous, differently located, and of different character, so 
there is great difference in the gravity of the cases. 

Idiopathic constipation generally comes on gradually. It at first attracts 
little attention and is neglected. The symptoms of course vary greatly 
according to the degree and stage of constipation. In mild cases the reten- 
tion is only in the rectum or rectum and sigmoid flexure, and there are no 
marked symptoms except a sensation of fulness or distention of these parts, 
which one or two evacuations relieve. Between these mild cases and the 
graver forms of constipation there is every intermediate grade, attended by 
symptoms proportionately severe. It is surprising sometimes to observe how 
long patients live with extreme constipation, though with constant suffering 
and ill-health ; and I wish it especially to be noticed in this connection that 
a large proportion of the fatal cases of idiopathic constipation occurring in 
adults and recorded in the literature of the profession began in early life, 
even in infancy, at which time they probably might have been relieved by 
proper remedies and a life of suffering prevented. This important practical 
fact shows the need of greater attention on the part of parents and nurses to 
the state of the bowels in children, that their sluggish action may be cor- 
rected before it becomes habitual and those anatomical changes of distention 
and muscular paralysis occur which are with difficulty corrected. 

A case quite remarkable and of recent date occurred in the practice of Dr. 
Strong 1 of Westfield, N. Y. : 

Case. — This patient at the age of two years usually had one stool in two weeks, 
and several years later only one in six weeks. When an adult he was treated by 
Dr. Strong, who found great distention of the abdomen, so that the lower ribs were 
pressed outward in nearly a horizontal direction, and the thoracic organs upward, 
so that the apex-beat of the heart was about one inch above the nipple. At this 
1 Amer. Journ. of Med. Sei., 1874 and 1876. 



CONSTIPATION. 759 

time months elapsed between the stools, the longest intervals being eighteen months 
and sixteen days. Defecation when it did occur lasted from two to four days, and 
was attended by violent gastric and intestinal pain, vomiting, and prostration. At 
one of these prolonged stools forty pounds of feces, resembling, as it usually did, 
chewed brown paper, were evacuated, the quantity being accurately ascertained by 
weighing the patient before and afterward. He had appetite and was able to do 
certain kinds of farm-work during the year preceding his death, which occurred at 
the age of twenty-eight years. At the autopsy the colon was found to have a 
length of sis feet' and three inches and a circumference of thirteen inches, while 
the lungs were pressed upward and backward as when compressed by a pleuritic 
exudation. 

While such extreme cases are infrequent, all physicians of experience are 
consulted from time to time by adults who have had habitual constipation 
from their earliest recollection ; and these cases, that aggregate so large a 
number, might, there is little reason to doubt, have been prevented for the 
most part during childhood when the habit was being formed. 

In long-continued constipation, in which there is a large fecal accumula- 
tion, not only is the diameter of the colon increased, as stated above, but this 
part of the intestine becomes elongated. This may lead to change in its 
position, the curves of the sigmoid flexure extending farther to the right, 
and the central part of the transverse colon by its weight curving downward. 
This abnormal lengthening and the consequent curvatures have a tendency 
to increase the constipation, as has been stated above in our remarks relating 
to the etiology. 

In these cases of extreme constipation, which fortunately are rare in chil- 
dren, as they are also in adults, the distention of the colon at the ileo-csecal 
orifice has a tendency to widen this orifice, so that the valve, which in the 
ordinary state prevents the return of any substance which has once passed 
by it, is liable to become insufficient. The adjacent folds which constitute 
the valve become separated, so that, if vomiting and antiperistaltic move- 
ments occur, fecal matter may pass from the colon toward the stomach. In 
aggravated cases, in which there is retention of a large amount of fecal mat- 
ter, distention, muscular paralysis, etc., similar to those which we have seen 
produced in the colon, are liable to occur, though to a less extent, in the 
small intestines, especially in the ileum. 

Retained excrementitious matter accumulating in large masses evidently 
becomes an irritant, so that by its pressure it excites muscular contractions, 
which if ineffectual in propelling the mass cause colicky pains. The retained 
fecal matter also undergoes more or less decomposition, producing gases which 
by increasing the distention also increase the pain. 

Any irritating substance applied to a mucous surface is liable to excite 
increased secretion from the mucous follicles or from the glands whose ori- 
fices connect with the mucous membrane at the point of irritation. Many 
familiar examples will at once be recalled to mind, as the defluxion from the 
nostrils from the use of snuffs and increased mucous secretion and salivation 
from objects held in the mouth. In the same way, retained excrement, form- 
ing hard masses which press upon the intestinal surface, excite a secretion, 
and not infrequently produce thereby a diarrhoea which is conservative, and 
which may for the time unload the bowels, or it may remove a part of the 
scybalse, while the rest remain. Hence we sometimes hear patients speak of 
having irregular evacuations, constipation alternating with diarrhoea. In 
aggravated cases the pressure of impacted feces sometimes produces inflam- 
mation of the surface, when, in addition to abdominal pain, there are tender- 
ness on pressure and some (usually quite moderate) elevation of tempera- 
ture. In cases which have terminated fatally after a longer or shorter 
time destruction of the mucous surface has been found in places in conse- 



760 LOCAL DISEASES. 

quence of the pressure and inflammation. "We can readily believe that, as 
in cases of typhoid ulcerations, if the ulcers reach a certain depth they may 
also give rise to localized peritonitis, and that occasionally perforation may 
result at the ulcerated or gangrenous point. The expulsion of hardened 
masses which have collected in the rectum is slow and painful, and accom- 
panied by more or less tenesmus, which not infrequently causes a portion of 
the mucous membrane at the anal orifice to descend below the sphincter ani 
and protrude, by which hemorrhoids are produced. Occasionally, as I have 
observed in certain cases, the entire circumference of the rectal mucous mem- 
brane, to the distance of half an inch or more above the anus, becomes so 
loosened from its attachment to the connective tissue that it descends below 
the sphincter ani and protrudes during each defecation. But this displace- 
ment, known as prolapsus recti, more commonly results in children from pro- 
tracted intestinal catarrh, attended by diarrhoea, loss of flesh, and by dimin- 
ished tonicity of the tissues. 

A beautiful and conservative provision in the system is that by which 
vicarious functions are established to relieve organs which imperfectly per- 
form their part. While the intestinal surface is to a great degree elimina- 
tive, so that noxious and effete products are largely expelled from the system 
in the stools, it possesses also in high degree an absorbent function, as all 
who employ rectal alimentation are aware. Xow, if the intestine fail to per- 
form its function of defecation and feculent matter collect within it and 
begin to exert pressure upon the intestinal surface, more or less of the liquid 
portion is taken up by the vessels, and, entering the general circulation, finds 
a mode of escape through other emunctories. The general ill-health or 
languor, the furred tongue, headache, and foul breath which characterize these 
cases are. no doubt, due to the absorption into the blood or retention in it of 
noxious products contained in, and which in part constitute, the feculent 
matter. The fact that patients may live for years with tolerable appetite, 
and with only one dejection every second or third week, receives explanation 
in the fact that other organs, as the lungs, kidneys, skin, etc., act as depur- 
ants for such excrementitious matter as can be taken up in a liquid or gas- 
eous form by the intestinal surface. 

In infants, constipation, even when slight and temporary, often causes fret- 
fulness, which is indicated by the character of their cries and the movement 
of the thighs over the abdomen. Continuing for a time, it causes more or 
less fever, and in those young children who are liable to eclampsia it predis- 
poses to an attack, and it may be the chief cause. 

Treatment. — If there be reason to suspect the presence of a mechanical 
obstacle which prevents normal defecation, a careful examination should be 
made in order to discover, if possible, its nature and location. Often it is 
of such a nature that it cannot be removed, but its constipating effects may 
sometimes be in a measure obviated. In one of the published cases in which 
constipation continued from early childhood to adult life, and finally proved 
fatal, its cause was ascertained to be a septum in the rectum, which probably 
might have been relieved by surgical measures. In all cases of constipation 
which the history shows may be produced by mechanical causes, whether the 
obstruction be complete and the colicky pains and other symptoms severe, or 
there be occasional scanty evacuations with but slight or moderate suffering, 
the history of the patient should be obtained in order to ascertain if there 
had been at any previous time symptoms of peritonitis or other pathological 
state which might throw light on the etiology. The abdomen and the usual 
sites of hernia should be carefully explored by palpation, and the rectum by 
the finger, large-sized catheter, or rectal tube. A thorough examination thus 



COXSTIPA TION. 761 

instituted, painless to the patient, will usually enable the practitioner to deter- 
mine either the exact or probable obstacle if any be present. 

The proper treatment of symptomatic constipation obviously requires the 
removal, so far as possible, of the primary disease or the cause, whether it be 
obstructive or otherwise. We need not stop to consider the special meas- 
ures which are required, and will pass to the consideration of the treatment 
of idiopathic constipation. 

Hygienic Measures. — We have already alluded to the fact that habit has a 
powerful control over the action of the intestines, so that it is important to 
obtain a daily alvine evacuation at a certain hour, and by establishing the 
habit the need will usually be experienced when that hour arrives each day. 
Many cases which become troublesome and obstinate might no doubt have 
been prevented had this physiological law been heeded and a daily evacuation 
obtained at a certain hour. The constipated habit, mild and not yet fully 
established, is more liable to be overlooked when it occurs in childhood than 
in infancy, for the infant is closely and constantly under observation, and it 
soon presents symptoms, as fever and fretfulness, if it do not have the regu- 
lar evacuation, while children over the age of four or five years tolerate better 
a sluggish state of the bowels, and are likely to be constipated for a consider- 
able time before the fact is ascertained. They therefore require more atten- 
tion in this regard than is usually bestowed by parents. 

The nature of the diet is obviously important, since certain kinds of food 
are more laxative than others. Chicken tea and, to a certain extent, beef 
and mutton tea, are laxative, and made plainly are therefore useful in con- 
nection with other articles. The apple scraped or baked, or apple sauce, may 
be given to quite young children, and for those that are older certain dry 
fruits, as prunes and figs, are laxatives. Unfermented cider in its season, 
which has been found so useful for adults, may also be given to children in 
moderate quantity, at least to those who have reached the age of two or 
three years. 

Oatmeal is more laxative than most other kinds of amylaceous food. 
Made into a gruel and strained, it may be given to the nursing infant, and 
unstrained to those who are older. Bread or pudding from coarsely-ground 
or unbolted flour or meal, and vegetables which contain saline and fibrous 
substances, have a stimulating and laxative effect on the surface of the intes- 
tines, and therefore are useful for constipated children of the age of two or 
three years and upward. Also farinaceous food treated by diastase may be 
employed. 

There can be no doubt that the free use of water in the ingesta materially 
aids in relieving costiveness. In one of the numbers of the London Lancet 
a physician asks the profession how to cure obstinate constipation in adults. 
Among the replies, one physician suggests drinking a tumblerful of cold 
water on retiring to bed and another tumblerful in the morning ; and there 
can, I think, be little doubt that the laxative effect of broths, gruels, fruits, 
and mineral waters is partly due to the amount of water which they contain. 
One of the chief causes of constipation, we have seen, is too great firmness 
or consistence of the stools, due to absorption of the water ; and if a larger 
quantity of water be swallowed during or after the meals than is removed b} r 
absorption, so that the stools have their normal or less than normal consist- 
ence, this cause of constipation is removed. An excess of water introduced 
into the system is to a great extent eliminated by the kidneys, and in hot 
weather by the skin, and to a certain extent exhaled from the lungs ; but 
experience shows that if the amount of liquid received be so great that the 
vessels in the coats of the intestines continue in a state of repletion, only a 



762 LOCAL DISEASES. 

certain part of it is absorbed, while the rest descends and mixes with the 
excrementitious matter and acts as a laxative. 

Another safe and effectual aid in overcoming habitual constipation 
is frequent kneading of the abdomen. My attention was first particularly 
directed to this in the treatment of the case related above, in which obsti- 
nate constipation, occurring in a child of three years from peritoneal bands 
and adhesions, was to a great extent corrected by friction over the abdo- 
men for three or four minutes at a time, with cod-liver oil three or four 
times daily. The manipulation probably did the good, and not the oil, but 
the use of one of the oils for inunction renders the kneading less painful 
and ensures its more thorough performance by the nurse. All obstetricians 
in certain emergencies stimulate the uterine muscular fibres to contraction by 
kneading the abdomen, and it is probable that the muscular fibres of the 
intestines are stimulated in a similar manner, so that the intestinal move- 
ments are increased by which feculent matter is carried forward. 

The external application of cold, so effectual in contracting the uterine 
muscular fibres, also stimulates the contractile power of the muscular fibres 
of the intestines. Cold-water bathing, the sudden application of a cloth 
wrung out of cold water to the abdomen, and in certain obstinate cases even 
the douche, may be used to stimulate the muscular coat of the intestines and 
the abdominal muscles to greater activity. Trousseau says : " Before leaving 
the subject of the treatment of constipation, let me refer to the application 
of cold to the abdomen — a minor method which I have seen recommended,, 
and have myself prescribed with astonishing success. On rising in the morn- 
ing let there be placed on the abdomen a compress of several folds soaked in 
cold water, and let it be separated from the clothes by a sheet of gutta-percha 
or caoutchouc. This compress ought to remain on for three or four hours." 
This recommendation by Trousseau is for adults, who are much less suscept- 
ible to the influence of cold than children. So prolonged an application of 
cold and wet to a child, even the most robust, would involve danger, while its 
application during the brief period occupied in an ordinary bath, with proper 
exercise afterward or with other measures to prevent chilling, could have no 
ill-effect. 

Therapeutic Measures. — For temporary constipation and many cases that 
are habitual enemata should be employed, since they promptly unload that 
part of the intestines in which feculent matter is ordinarily retained, while 
they do not impair the appetite or produce the prostration which so often 
results from purgatives. For temporary constipation a warm clyster may be 
given, and it commonly is more agreeable to the patient than one of lower 
temperature than the body. Among the enemata which have been found 
useful are castile soap with molasses and water, salt and water, the various 
oils, as sweet oil with or without castor oil, linseed oil alone or with molasses, 
and the gruels, as that of oatmeal or cornmeal made thin. The belief that 
the frequent use of warm clysters produces a relaxing effect is probably cor- 
rect, so that if it be necessary to employ clysters often in consequence of the 
torpid state of the intestines, cool water, the effect of which is tonic and stim- 
ulating, should be used. I prefer the use of glycerin and water as a laxative 
enema. For ordinary constipation in an infant the injection into the rectum 
of one teaspoonful of glycerin and one teaspoonful of water from a gutta- 
percha or glass syringe, at a certain hour each day, will rarely fail to give 
relief. 

For infants, a clyster of* one or two ounces usually suffices, administered 
by a gutta-percha or glass syringe, while for older patients a proportionately 
larger quantity is required, administered by preference through a Davidson, 
India-rubber, or a fountain syringe. In certain long-continued, aggravated 



CONSTIPATION. 763 

cases the frequent injection of a large quantity of tepid water is indispensa- 
ble in order to wash away the accumulation of fecal matter. Thus in 1854, 
Mr. Gay exhibited to the London Pathological Society a boy of seven years 
who at the age of three years had had typhus fever with dysenteric stools. 
After convalescence he had habitual obstinate constipation, so that when Mr. 
Gay began treatment there had been no fecal evacuation for nearly four 
months, and the girth of the body over the abdomen was forty-nine inches, 
and yet the appetite and general health were not seriously impaired. The 
shape of the abdomen and the examination showed great distention of the 
rectal ampulla and the descending colon. Mr. Gay first distended the 
sphincter ani, so that it admitted a speculum, and through a rectal tube, well 
introduced into the colon, the excrement was repeatedly washed away, so that 
at the time of the exhibition of the boy to the society the measurement in 
girth gave only twenty-four inches. Evidently in cases like the above no 
other treatment except repeatedly washing out the intestines with warm water 
would have answered, and the dilatation of the sphincter ani and the 
introduction of the speculum to facilitate the escape of fecal matter are 
noteworthy. 

Suppositories may sometimes be usefully employed in place of enemata ; 
cocoanut butter, molasses candy, or soap cut in shape of a pencil may be 
used for this purpose. In the adult, long-continued constipation is not very 
rare in which the rectal ampulla becomes so impacted that it is necessary to 
use the anal curette, the handle of a spoon, or the finger introduced, in order 
to break up the masses and allow them to pass. In children necessity for 
such treatment is much more rare, but there are occasional cases, like that 
above described by Mr. Gay, in which it may be needed. Dr. Nagel states 
that the evil may be removed by the introduction of a suppository of brown 
gelatin. This is steeped in water for twelve hours, and, having been thus 
softened, is introduced into the rectum and an evacuation obtained. The 
doctor attributes the laxative effect to the hygrometric action of the gelatin. 
The glycerin suppository of the shops is also very effectual. 

The known effect of the galvanic current in producing contraction of the 
uterine muscular fibres suggests its employment to relieve constipation by 
stimulating the muscles of the abdomen and the muscular coats of the intes- 
tines ; and those who have employed it speak favorably of its use. Habershon 
says : " A galvanic current, transmitted through the abdominal walls, induces 
a very speedy action, or rather emptying, of the colon. .... A case of 
partial paraplegia, in which injections did not act satisfactorily and drastic 
purgatives were undesirable, was treated by a galvanic current passed through 
the abdomen every morning. In a few hours a free evacuation was produced 
without any discomfort." But the constipation of children very seldom 
requires the use of galvanism. 

The ordinary purgatives should not be given habitually to relieve a con- 
stipated habit. They are liable to irritate the intestines, causing a catarrh, 
or else the intestines become accustomed to their action and a larger dose is 
needed to effect purgation. Given habitually, they cannot fail also to disturb 
the digestive and nutritive processes. One or two doses for present relief, 
both in habitual and temporary constipation, are sometimes required, provided 
that an injection is for any reason not preferred. For this purpose, castor 
oil or a few grains of calomel mixed with syrup of rhubarb, the syrup of 
senna, or the compound liquorice-powder of the German Pharmacopoeia, may 
be administered with advantage. But for habitual constipation I strongly 
advise to discard the ordinary purgative medicines, and, if the measures of 
a dietetic or hygienic character recommended above are not sufficient, to 
employ such remedial agents as promote, or at least do not impair, nutrition. 



764 LOCAL DISEASES. 

Probably the best purgative for habitual use is rnaltine with fluid extract of 
cascara sagrada. 

Belladonna, so highly recommended by Trousseau and others. I have often 
administered to children, especially in pertussis, in large doses during several 
consecutive days, but it has not seemed to me to have any decided laxative 
effect. Though it may be useful in certain mixtures for adults, our experi- 
ences in this country with reliable preparations certainly have not been such 
as to justify its employment as the sole or main remedy for constipation. It 
diminishes reflex irritability, and may render the action of purgatives less 
painful, but from its known physiological effects we cannot believe that it 
increases the intestinal secretions or the action of the muscular fibres, one or 
the other of which results we expect from the use of an agent which is really 
laxative. On the other hand, nux vomica and its active principle, strychnia, 
are doubtless valuable adjuncts to purgative mixtures from their effect in 
increasing the action of muscular fibres. 

Physicians are not infrequently at a loss what to prescribe for the habitual 
constipation of nursing infants, which is by no means infrequent. But 
recollecting that colostrum is more laxative than ordinary milk, and that it 
differs from it in containing more sugar, salts (largely phosphates), and butter, 
we have a hint, as stated above, as to what is probably lacking in the milk, 
and what, therefore, should be supplied. I am in the habit of giving the oil, 
sugar, and salts in the following formula, and usually with the desired laxa- 
tive effect : 

R. 01. morrhuae, 2 parts ; 

Aq. calcis, 
Syr. calcis lactophos. , da. 1 part. 

One-quarter, one-third, or one-half teaspoonful may be given with each 
nursing, or a larger quantity, as a teaspoonful or more, three times daily. 
Breast-milk with this addition becomes more nearly like colostrum in its 
laxative properties, while it does not possess those properties of colostrum 
which disturb the digestive process. I know no agent of a medicinal nature 
which meets the indication so well as this for infantile constipation. But in 
my practice I have found it necessary, in not a few instances, to rely mainly 
on enemata of glycerin and water for the relief of the constipated habit till 
the infants reached the age when a mixed diet was proper. 

The habitual constipation of older children may ordinarily be relieved by 
the remedies recommended above, but occasionally a more active purgative 
effect may be needed. Since the portion of intestine which is chiefly impli- 
cated in ordinary forms of constipation is the colon, it is evident that if it be 
necessary to employ frequently any of the active purgatives of the Phar- 
macopoeia, such should be selected as produce little or no irritation of the long 
tract of the small intestines, while they stimulate the function of the colon. 
The aloetic preparations are used for this purpose, as the tincture of aloes 
and myrrh or the simple tincture of aloes, which may be given in dose of 
part of a teaspoonful in a convenient syrup or in coffee or milk. But I think 
a preferable remedy is maltine with fluid extract of cascara sagrada, as 
recommended above, a half teaspoonful of which may be given daily, if 
necessary, to a child of eight years. 



INTESTINAL WORMS. 765 

CHAPTER XI. 

INTESTINAL WORMS. 

The belief has been prevalent in the profession in former times, and is 
now among the people, that worms in the intestines constitute a frequent 
disease, especially in children. As pathology and the means of diagnosticat- 
ing diseases are better understood, this idea has been gradually abandoned 
by physicians and the intelligent portion of the community. Still, these 
parasites must be considered an occasional cause of serious derangements, 
and in rare instances a cause even of death. They indeed often exist in 
small numbers without producing any appreciable deviation in the individual 
from the healthy state ; but the most common and best-known species, when 
they have once effected a lodgement in the intestines of man, ordinarily grow 
and multiply so as to produce symptoms and require medicines for their 
expulsion. 

So far as is now ascertained by observations in different countries, about 
fifty animal parasites make their abode in man. It is not improbable that 
the number will yet be found greater by observations in distant uncivilized 
countries. Of these fifty, twenty-one reside in the alimentary canal (Heller), 
several of them being microscopic. Of those occupying the intestines only, 
the following species are specially interesting to the practising physician on 
account of their relation — for the most part causative — to certain path- 
ological states : to wit, the ascaris lumbricoides, or round-worm ; the oxyuris 
vermicularis, or thread-worm ; the bothriocephalus latus ; and three species 
of taenia, or the tape-worm ; and the trichocephalus dispar, or whip-worm. 

Ascaris Lumbricoides. — The round-worm has a dingy reddish or yellowish- 
red color and a cylindrical form, tapering toward both extremities from the 
point of its greatest diameter, which is a little posterior to the middle. The 
dead worm is paler than the living. The anterior extremity is tipped with 
three nodules, between which and the body is a circular groove. Between 
these nodules anteriorly is the aperture of the mouth, from which the oesoph- 
agus extends to the distance of one-fourth to one-third of an inch. The intes- 
tine, which has a light brownish color, extends from the oesophagus to near the 
posterior extremity of the animal, where it terminates in the anus. The fe- 
males are in numerical excess of the males, and their size is also greater. 
The shape of the worm is like that of the common earth-worm, from which 
it derives the name lumbricus, but it is somewhat more pointed and its color 
paler red. The tail of the male worm is curved like a hook, while that of 
the female is straight. 

The total number of eggs contained in a fully-developed female has been 
estimated at sixty millions. The eggs when immature are conical and are 
attached to a longitudinal band ; when mature they are oval, with dark gran- 
ular contents and a strong double shell, and their diameter is about --i--^ of 
an inch. They are expelled in countless numbers with the feces, and at the 
time of expulsion are surrounded by an albuminous coating stained with bile. 
Their vitality is retained under apparently very unfavorable circumstances, 
even for years. They hatch after they have been repeatedly frozen or 
desiccated. 

The ascaris lumbricoides inhabits the small intestines, where it is rapidly 
developed from the embryonic state. The remark made by Heller, that when 
found in the colon it is always dead, cannot be true, for many live worms are 
expelled in the stools. 



766 LOCAL DISEASES. 

The round-worm, more than all other intestinal worms, is inclined to wan- 
der away from its usual abiding-place — namely, from the jejunum and ileum 
— producing symptoms of more or less gravity referable to the part over 
which it crawls. It occasionally enters the stomach, from which it is vom- 
ited, or it ascends the oesophagus into the fauces, from which it is soon 
removed by the efforts of the individual. Cases are on record — one of which 
Andral witnessed — in which the worm entered the larynx, producing suffoca- 
tion and speedy death. M. Tonnelle also witnessed such a case. A child 
nine years old was suddenly seized with great difficulty of respiration and 
pain in the upper part of the chest. A careful examination of the thorax 
gave a negative result. Death occurred in from twelve to fifteen hours, and 
at the post-mortem examination a iumbricus was found filling the cavity of 
the larynx. M. Blandin also witnessed a case when interne of the Hopital des 
Enfants. An infant was suffocated by one of these worms, which had pene- 
trated as far as the right bronchus. Very rarely they crawl from the fauces 
into the nasal passages. This worm is so strong and active that there is no 
recess or reflexion of the mucous membrane of the digestive apparatus which 
it could possibly penetrate in which it has not been found. It has been dis- 
covered in the appendix vermiformis. in the pancreatic duct, in the common 
bile-duct, and even in the gall-bladder. The number of these worms found 
in the intestines varies. There may be only one worm or the number may be 
incredibly large. Thus, Barrier relates the case of an infant thirty months 
old who died in Hopital Xecker. It was believed to be tubercular. Numer- 
ous tumors which could be felt in the abdomen were supposed to be tuber- 
cular masses. On making the post-mortem examination the mesenteric glands 
were found healthy, but the intestines throughout their entire extent were 
filled with lumbrici. The masses which during life were supposed to be 
tubercular glands were found to consist of worms. The caecum especially 
was greatly distended by them. The intertwining or collection in balls of 
these worms constitutes, indeed, one of the chief dangers, as it renders them 
so much the more difficult of expulsion. 

The round-worm possesses no organs of penetration ; still, if the intestine 
be weakened by disease, especially by ulceration, it may, by pressure with its 
head, force an opening, through which it escapes into the cavity of the abdo- 
men, causing peritonitis and death. This worm is commonly found, whether 
single or in masses, surrounded by mucus, which serves as a partial protec- 
tion to the intestines. The length of the male round worm is about four to 
six inches ; that of the female, eight to ten inches. 

The portion of the mucous membrane in contact with lumbrici is often 
found inflamed, either from movements of the worm or from pressure of a 
mass of worms, or even of a single worm in a confined position, as the 
appendix vermiformis. This inflammation, continuing and increasing, may 
end in ulceration, and thus a weakened spot be produced which may be rup- 
tured by simple pressure of the mouth of the worm. In this way are to be 
explained those apparent cases of perforation which have led some observers 
to believe that lumbrici have actually the power of penetrating the healthy 
coats of the intestines. The perforation is obviously most liable to occur in 
those who have been enfeebled and whose tissues have been rendered less 
firm and resisting by antecedent disease, as by typhoid fever. 

M. Guersant describes a case in which the appendix vermiformis con- 
tained an ulcerated opening through which two round-worms had partly 
passed into the abdominal cavity, producing fatal perityphlitis. The effect 
of their impaction in this narrow cul-de-sac was much like that of a bean or 
a seed lodged in the same situation. 

The ascaris lumbricoides has occasionally been found in the most remark- 



INTESTINAL WORMS. 767 

able locations — namely, in abscesses lying without the intestines. They 
have been known to effect a lodgement in the liver and produce an abscess 
there, no doubt by crawling up and distending a bile-duct. Their lodgement 
in other viscera which have no pervious connections with the intestinal tract 
is probably accomplished through fistulous openings produced by inflamma- 
tion, which they had no part in causing, as, for example, in the bladder and 
kidneys, of which there are well-authenticated cases. Worm -cysts in the 
abdominal walls have been found to occur in most instances in the usual site 
of hernias — namely, at the umbilicus in children and in the inguinal region 
in adults. It is presumed, therefore, that the worms had entered hernial 
protrusions, from which they had passed by ulceration into the abdominal 
walls, and had there become encapsulated. 

The oxyuris vermicula/ris, or thread-worm, so called from its resemblance 
to pieces of ordinary white sewing-thread, is also frequent in childhood and 
not infrequent in the adult. The length of the male oxyuris is from one- 
sixth to one-fifth of an inch ; that of the female, from one-third to one-half 
an inch. The posterior extremity of the male is blunt, and is curved or 
rolled up toward its abdomen ; that of the female is slender and pointed like 
an awl. 

The head of this worm is relatively broad, from an unusual thickness or 
fulness of the cuticle, and the mouth, surrounded by u three nodular lips," 
is situated in the centre of the extremity. The oesophagus extends back- 
ward from the mouth, gradually growing larger like the segment of a long 
and narrow cone, and ending in a globular enlargement which has been desig- 
nated the pharynx. From the pharynx the intestine runs in nearly a straight 
line through the worm. 

The eggs are numerous, so completely filling the interior of the female 
as to conceal the organs from view. They are flattened on one side, but are 
rounded or convex on other parts of their circumference. One end is more 
pointed than the other, as in the eggs of birds. Certain of the eggs in the 
mature female are seen to be undergoing segmentation preparatory to hatch- 
ing, while others more advanced contain tadpole-shaped embryos, and others 
still contain worm-shaped embryos either lying within the shells or protrud- 
ing from them. The hatching and growth of this worm, which have been 
observed under the microscope, are very rapid under favorable circumstances. 
'• I once," says Heller, " saw the metamorphosis from the tadpole-shaped 
embryo to the worm-shaped embryo completed in about one hour," but the 
usual time is longer. Leuckhart saw oxyurides one-fourth of an inch in 
length fourteen days after the eggs had been swallowed. 

Oxyurides may be developed so rapidly from eggs swallowed in the 
ingesta that they attain nearly or quite their full growth while still in the 
small intestines, so that, although their chosen residence is in the large intes- 
tines, some of them are not infrequently found in the ileum, and even in 
the jejunum, of full size and active. The part of the intestinal tract which 
the oxyurides prefer, and in which the largest colony of them reside, is the 
caecum and appendix vermiformis, and not in the rectum, as stated in most 
of the books; and in this situation, where they have been little disturbed, 
their habits and the relative proportion of the sexes can be best observed. 
But they are ordinarily found both in the caecum and rectum in the same 
individual, and indeed upon all parts of the intervening surface of the colon. 

The number of oxyurides in the individual varies greatly. They are 
occasionally so numerous upon the intestinal surface that the} 7 resemble fur, 
and when they are so abundant they are commonly found above the ileo- 
caecal valve as well as below it. The males are smaller and apparently more 
fragile and perishable than the female. Therefore in the rectum and other 



768 LOCAL DLSEASES. 

exposed situations there is a numerical excess of the females ; but in reflex- 
ions of the intestines, where they are securely lodged, as in the appendix 
vermiformis, no marked difference has been observed in the relative number 
of the two sexes. Since the males are more delicate, transparent, and 
smaller than the females, they are more likely to be be overlooked in a hasty 
post-mortem examination. 

The term tape-worm is applied to several species of the taenia and to at 
least two species of the bothriocephalus, but all except four — to wit, the 
taenia solium, taenia saginata or medio-canellata, taenia elliptica or cucumer- 
ina, and the bothriocephalus latus— are rare in Europe and North America, 
and are therefore of little interest to the practising physician. 

The tape-worm is an hermaphrodite, each segment containing the two 
sexual organs. The head, or scolex, is small, or about the size of a pin's 
head, and segment after segment is produced by a budding process from the 
head. The segments are attached to each other at their extremities, and each 
segment as it becomes farther and farther removed from the head by the 
formation of new intervening segments at the upper end of the chain, 
becomes also larger and more matured. The oldest segments, having 
attained their full growth, are detached, and have an independent existence. 
A separation of the chain of segments at any point does not compromise the 
life of the parasite. If only the head remain uninjured, the segmentation 
continues from it, and in time the former number of segments and former 
length of the chain are restored. This worm resides in the small intestines, 
the larger species sometimes extending from the upper part of the jejunum 
to near the ileo-caecal valve. 

The taenia solium is developed from an embryo known as the cysticercus 
cellulosae contained in the muscles of the hog. It has also been found in 
some other animals, as the dog, deer, and polar bear. It is a vesicle about 
the size of a pea or small bean, having a delicate cell-wall, and is nearly 
spherical, except as its shape is changed by compression between the muscu- 
lar fibres. At one point of the cell-wall is a depression, attached to the 
inner surfaces of which, and lying within the cyst, is a whitish, pear-shaped, 
solid body, which is the head of the cysticercus, and is identical in appear- 
ance and character with the head of the taenia solium turned inside out. 
Many experiments have shown the close relationship of the cysticercus and 
taenia solium — that they are two forms of existence of the same parasite. 
Segments of the taenia solium have been repeatedly fed to pigs, and the 
cysticercus produced in their muscles, though in what way the ovum or 
embryo passes from the stomach to the muscles is not known. On the other 
hand, swine-flesh containing cysticerci has been fed to animals who were 
soon after killed, when the taenia was found in their intestines. It is evident 
that this parasite occurs only in those who eat swine-flesh, as sausages, either 
raw or but slightly cooked. 

The head of this species of taenia, which is about the size of a small pin's 
head, has at the top a conical protuberance, upon which is a corona of hook- 
lets arranged in two circles, the hooklets of the outer circle being smaller 
than those of the inner. The projecting points, however, of the two rows 
fall together, forming one circle. The hooklets are inserted into depressions 
in the head, and many of them have fallen out in most specimens which we 
have had an opportunity of examining. The depressions in which the hook- 
lets are lodged are often dark from pigmentation. Back of the circle of 
hooks are four sucking disks, which the worm is able to protrude and move 
freely. When protruded they appear as small tubercles with slender pedi- 
cles. The neck, which is slender and about one inch in length, shows mark- 
ings from commencing segmentation, and it is succeeded by very small and 



INTESTINAL WORMS. 769 

delicate segments, which gradually increase in size as the distance from the 
head increases. 

The mature segments (proglottides) vary in size accordingly as they are 
in a state of contraction or relaxation. When relaxed their length is about 
half an inch and breadth one-quarter of an inch. The genital organs are 
situated on the margin of each segment, a little posterior to the middle, and 
there is an alternation in their location between the right and left margins in 
the chain of segments. The uterus lies in the centre of the segment, form- 
ing a longitudinal straight line. From seven to twelve branches are given 
oft' from each side of the uterus, and these divide and subdivide like the 
branches of a tree. The male genital organs lie in the same aperture or 
pore in the margin of the segment, with which the uterus and ovaries 
connect. 

The eggs of the taenia solium are globular, with a diameter of about 
yi^th of an inch, and with thick shells, which are striated like mosaic-work 
by lines which cross each other. It is estimated that not less than fifty mil- 
lion eggs are contained in all the segments of a matured taenia. 

This parasite is very liable to abnormal development. In some instances 
two or more segments are fused together, and often they are stunted in their 
growth, or they contain holes, fissures, and flaws, either from their original 
development or produced by rupture of the distended uterus. Again, rarely, 
two taenia are blended, so that along the flat side of one chain another is 
united by the margin, so that a section of the double parasite resembles the 
Roman letter T or Y. The nutrition of the segments is maintained through 
a vessel running the whole length of the worm near each margin and having 
communicating branches. 

The taenia saginata, designated also medio-canellata, is much larger, stronger, 
and thicker, both as regards the head and segments, than the taenia solium. 
When fully matured it measures eighteen feet. The diameter of the head is 
nearly one line (yf-g- inch). It is furnished with four strong sucking-disks, 
but it lacks the circlet of hooks which characterizes the taenia solium. Instead 
of the hooks the head is furnished with a small frontal sucking-disk. The 
heads of some specimens of this worm are free from pigment, but other 
specimens present various shades of pigmentation, from a slight staining to a 
jet-black color. The neck is short, and very near the head are markings 
which indicate commencing segmentation. The matured segments vary in 
measurement when relaxed — from a length of eight lines and breadth of two 
lines to a length of nine lines and breadth of three lines. As in the taenia 
solium, the genital pores are situated on the margins of the segments, vary- 
ing irregularly from side to side, and the uterus has lateral branches which 
divide dichotomously. There is but little difference in the sexual apparatus 
of the taenia solium and taenia saginata, but the eggs of the latter are some- 
what larger than those of the former, and are oval. 

The development of the taenia saginata is sometimes irregular, producing 
monstrosities, as in the taenia solium. The embryos of this parasite occur 
chiefly in the muscles of ruminating animals, as the ox, sheep, goat, etc., and 
therefore its presence in man is attributable to the use of the flesh of these 
animals, either slightly cooked or raw. The cysticercus of this species 
appears to be less tenacious of life than that of the taenia solium, and when 
it perishes it becomes changed into a greenish-yellow pulp, surrounded by the 
capsule and imbedded in the muscular or other tissue where it had lodged. 

It is easy to distinguish this worm from the taenia solium, if the head be 
found, by its larger size, the larger size of its sucking-disks, and the absence 
of the circle of hooks. The segments are distinguished by their greater size 
and greater number and the dichotomous division of the branches of the 

49 



770 LOCAL DLSEASES. 

uterus. This species occurs over a mucli greater area of the earth's surface 
than the taenia solium. 

The taenia elliptica or cucumerina is a more delicate worm than the pre- 
ceding species, measuring, when fully grown, from seven to ten or eleven 
inches in length. Upon its head is a rostellum or beak, which the worm is 
able to thrust forward, and on which are about sixty hooks irregularly 
arranged. The anterior portion of the parasite is very delicate, like a thread, 
and its segments are small, but, as in the other species, they become larger as 
their distance from the head increases. The matured segments, which have 
a reddish-white color, are readily detached, and when separated they move 
about actively. This taenia is also an hermaphrodite, and a genital pore con- 
taining a double set of genital organs is located on each margin of the seg- 
ment. The taenia elliptica inhabits the small intestines of the dog and cat, 
and many children in different localities have been affected with it. 

Heller states that the segments of another and rare species of taenia, 
which were expelled from a child of nineteen months, are preserved in the 
Museum of Pathological Anatomy in Boston. Nearly in the middle of the 
posterior half of each segment is a yellow spot — namely, the receptaculum — 
full of ova. and therefore the name flavo-punctata has been applied to this 
worm. Little is known in regard to the taenia nana and taenia Madagascarien- 
sis, since they occur in distant countries. 

The hotliriocephalus lotus is the largest of the tape-worms, attaining the 
length of fifteen to twenty-four feet. It is one of the most important of 
the intestinal parasites. The head has an almond-shape or the shape of 
an elongated and somewhat flattened globe, its length being about one 
line and its diameter from one-third to one-half a line. Running longi- 
tudinally along each flattened side of the head is a groove or fissure contain- 
ing the apparatus of suction. Those segments which are still in the process 
of growth have a breadth three or four times greater than their length, while 
the matured segments are nearly square. The genital pore occurs in the 
centre of one side of the segment, and in the chain of segments all the pores 
are found on the same side. A brownish, rosette-shaped spot is observed at 
the site of each ripe pore, produced by the convolutions of the uterus and 
the numerous eggs which this organ contains. 

The egg. which is oval, has a thin shell, a light-brown color, and at one 
end of it is a lid or operculum which is separated from the rest of the egg by a 
well-defined line. At the hatching an embryo provided with six hooks escapes 
from the lid. When it has separated from the egg it is provided with an 
albuminous covering from which cilia radiate in all directions, by the move- 
ment of which it is propelled. After a few days this covering is lost, and 
the embryo now moves about by amceboid extension and contraction. It is 
believed that in this embryonic state it enters an aquatic animal, a mollusk 
or fish, where it undergoes further development, and from the mollusk it is 
received into the stomach in the food. 

The bothriocephalus occurs not only in man. but also in some of the 
domestic animals which eat fish, as the dog. This parasite is believed to be 
rare outside of Europe, and in Europe it is chiefly met in countries bordering 
on inland lakes and seas. 

The trichocephalus dispar is comparatively unimportant to the physician, 
since it is uncertain whether it materially impairs the health or produces 
symptoms. It inhabits the caecum, but in rare instances it has been found 
in the ileum and appendix verniif oralis. The number of these parasites is 
usually small, but as many as seventy to one hundred have been observed in 
the intestine of the adult. 

The trichocephalus dispar occurs also in the monkey, and a very similar 



INTESTINAL WOBMS. 771 

if not identical worm has been found in the pig. It is not frequent in 
children, and has not been observed in the very young. It occurs in man 
in every part of the globe, and in some countries, as Egypt, Nubia, and 
Syria, it is said to be very common. This worm, which is also sometimes desig- 
nated the whip-worm from its shape, attains the length of one and a half to 
two inches, the female being longer than the male. Its anterior two-thirds 
are thin, delicate, and flexible, like a small thread. The posterior one-third, 
which contains the generative organs and intestinal canal, is considerably 
thicker, and it ends abruptly. On the under surface, extending nearly the 
whole length of the body, is a longitudinal band, the width of which is about 
one-third the circumference of the body. In the female the posterior or 
thick portion of the worm is slightly bent or curved like the stock of a hunt- 
ing-whip, while that of the male is rolled in the spiral form. The digestive 
tube consists of an oesophagus, which extends through the anterior thread- 
like part, and the stomach and rectum, which lie in the posterior thick 
division. The genitals of the female lie in the commencement of the thick 
portion, and the uterus, when distended with eggs, occupies nearly the whole 
of this section. In the male the pore which contains the genitals lies in the 
posterior extremity of the thick part, where it forms a cloaca with the termi- 
nation of the intestinal canal. The eggs, which are numerous, are oval, 
brownish, and with a glistening protuberance at each extremity, giving them 
the shape of a lemon. They have great vitality, hatching after repeated 
desiccation and freezing. Their development from the egg is slow. It is 
believed that the trichocephalus is produced directly from the egg, which 
has lodged in the intestine, and therefore does not have or require an inter- 
mediate stage of preparation in another animal. This parasite resides in the 
caecum, but when many are present some are found in the ascending colon, 
and occasionally a few are observed in the small intestine. 

The taenia is rare in early life, but it now and then occurs in young chil- 
dren. I have met cases in this city under the age of five years. Rosen and 
Bremser report cases between the ages of six and eleven years, and Hufe- 
land one at the age of six months. Wawruch collected 206 observations of 
taenia, in 22 of which the age was less than fifteen years ; the youngest was 
a girl of three years. A most remarkable case of taenia is reported in the 
Gazette medicate of Paris in 1837. M. Muller was called to treat a foster- 
child five days old for slight constipation. The bowels were evacuated by 
the use of rhubarb, manna, and a few grains of salt, and in the excrement 
a foot and a half of taenia were discovered. This worm had evidently existed 
during the foetal life of the infant. 

A similar case was treated by Prof. Skene in the Long Island Hospital in 
September. 1871, and reported by Dr. Armor. 1 The infant was born Septem- 
ber 3d of a hearty Irish servant-girl. On the 7th it refused to nurse, and 
was observed to have a mild form of tetanus. On the 8th, small doses of 
calomel having been given, followed by castor oil, two segments of a taenia 
solium were passed from the bowels, and on subsequent days ten more seg- 
ments, after which the tetanus ceased. The remedies employed after Sep- 
tember 8th were the oil of male fern and turpentine. The mother, who had 
presented no symptoms of taenia, was ordered an emulsion of pumpkin-seeds, 
which " she faithfully took for twenty-four hours, at the end of which she 
passed over seventy segments of taenia." This case is interesting as throw- 
ing light on a possible mode of the production of taenia quite different from 
the ordinary and recognized mode, and also as showing the causative relation 
of intestinal worms to tetanus infantum. 

Causes. — It is obvious that intestinal worms are developed from eggs or 
1 New York Medical Journal. 



772 LOCAL DISEASES. 

embryos which are introduced into the stomach in the ingesta. The eggs of 
the ascaris lumbricoides have been found by Mosler * in drinking-water, but it 
is_ probable that in most instances they are contained in fruits and vegetables 
which are eaten raw. The eggs of the oxyuris vermicularis are received 
from some one who is himself aifected with the disease. Both Zender and 
Heller state that they have frequently discovered ripe eggs of this worm 
around the nails of persons who were troubled with oxyurides — a fact readily 
explained from the itching which they cause. If these eggs are upon the 
fingers of the mother or nurse, it is easy to understand how they are acquired 
by the child. We can understand also why this worm is so common in 
degraded and filthy families. In reference to the etiology of the tape- 
worm nothing need be added to what has been stated above, and little is 
known in reference to the manner in which the eggs of the trichocephalus 
are received. 

Certain conditions of the intestinal surface favor the recurrence of worms. 
Thus children in advanced typhoid fever are not unfrequently affected with 
the ascaris lumbricoides. 

Symptoms of the Ascaris Lumbricoides. — These are in part constitu- 
tional and in part local, due to the mechanical effect of the entozoa on the 
coats of the intestines. Writers, especially Billiet and Barthez, have 
described with minuteness the symptoms supposed to indicate lumbrici. 
Those of a constitutional character are the following : Features at one time 
flushed, at another pallid, and in some children of a leaden hue ; lower eye- 
lids swollen, and sometimes surrounded by a blue semicircle ; thirst, nausea, 
or even vomiting ; appetite diminished or augmented or variable ; breath 
foul ; papillae of the tongue red and projecting ; pulse accelerated and irreg- 
ular. Billiet and Barthez state that they observed this irregularity of the 
heart's action in a boy three years old at the time he was passing a large 
number of lumbrici. The irregularity afterward disappeared. Acceleration 
of the pulse and increase in temperature are common symptoms of these 
worms, and hence the popular belief in a worm fever. This fever is often 
remittent and mild, but occasionally it is continuous and of a high grade. 

The symptoms pertaining to the nervous system are important. In mild 
cases these may be absent, as when there are few lumbrici and the child is 
robust and over the age of five years, but in severe cases certain neuropathic 
symptoms are frequently present, such as dilatation of the pupils, especially 
inequality of dilatation, to which Munro attached diagnostic value, strabis- 
mus, twitching of the muscles, clonic convulsions, somnolence, headache, neur- 
algic pains, delirium. Barely, chorea, deafness, and paralysis, it is believed, 
may result. 2 Dr. Leedom 3 of Montgomery county. Pa., relates the case of a 
boy of seven years who had night-blindness due to a large number of lum- 
brici in the intestines. By the employment of pinkroot and calomel these 
were passed and the blindness ceased. Hypersesthesia of the abdominal 
surface was present in a case which I attended, and which subsided as soon as 
the lumbrici were expelled. Grinding the teeth in sleep and picking the nos- 
trils are symptoms to which families attach great value. Observations, how- 
ever, show that though sometimes due to worms they more frequently have 
another cause. 

The local symptoms or disorders — in other words, those having a mechan- 
ical origin — are colicky pains, experienced chiefly in the umbilical region ; 
stools sometimes natural ; in other cases diarrhoea with fecal or muco-san- 
guineous stools ; flatulence. M. Davaine at a recent period made the import- 
ant discovery that the feces of patients affected with worms contain the ova 

1 Virchovfs Archiv, 1860. 2 Gaz. de Hopitaux, 1867. 

3 Amer. Journ. of Med. Sci., for July, 1867. 



INTESTINAL WORMS. 773 

of the particular species present in large numbers. These ova. which have 
been described above, can be seen through a lens magnifying one hundred and 
fifty diameters. 

In exceptional cases there are local symptoms, due to the presence of 
these worms in unusual situations, such as a crawling sensation in the oesoph- 
agus : a sense of constriction in this tube or the pharynx ; nausea and vomit- 
ing : a cough, especially if the worm have crawled to the upper part of the] 
oesophagus ; rarely the most urgent dyspnoea and probable suffocation if 
a lumbricus have entered the larynx. Earache and perhaps convulsions if 
the worm have entered the Eustachian tube (case Davaine, p. 144). The 
most dangerous symptoms arise from the crawling of the worm into narrow 
openings. 

The enteritis and colitis to which these worms sometimes give rise are 
ordinarily mild, but in rare instances ulceration occurs, which may be attended 
by profuse and even fatal hemorrhage. Occasionally very painful and 
dangerous constipation results from an accumulation of worms in a ball or 
mass too large to be expelled, unless with much delay and suffering, prevent- 
ing the passage of fecal matter and producing severe abdominal pains. The 
symptoms in these cases resemble closely those of intussusception. A marked 
example of constipation produced in this way occurred in a family with whom 
I am acquainted, and who then resided in the interior of this State. A little 
girl of three or four years was suddenly affected with obstinate constipation. 
The physicians prescribed active purgatives, calomel among others, and finally 
croton oil and various injections, without relief. There was great pain with 
distention of the abdomen, and death seemed inevitable, when after the lapse 
of several days a free evacuation occurred, and in the stool was a mass of 
worms firmly intertwined. 

Children often have lumbrici without any appreciable impairment of the 
general health, but their presence may intensify the symptoms of inter- 
current diseases and greatly increase the danger. Thus I recollect two 
children of three and three and a half years with pneumonia who at the 
same time had lumbrici, one passing in the course of a few days thirty and 
the other twelve of these entozoa. Both presented well-marked physical 
signs of pneumonia, and, though they recovered, the fever and nervous 
symptoms were apparently aggravated by the intestinal affection. One had 
convulsions in the commencement of the inflammation, followed by profound 
stupor and amaurosis lasting two or three days. 

Often the symptoms due to lumbrici coexist with those of a protracted 
and distinct intestinal disease. Thus, as we have seen, the intestinal secre- 
tions of typhoid fever and of chronic diarrhoeal maladies afford a nidus for 
the growth of worms, and accordingly at an advanced stage of these diseases 
lumbrici are common. 

The symptoms produced by the oxyuris vermicularis are somewhat differ- 
ent. These worms do not usually cause the fever, disturbed digestion, the 
colicky pains, or the dangerous nervous symptoms which arise from the 
presence of lumbrici. Nor do they, like lumbrici, endanger life by crawling 
into unusual situations. In one recent case I could detect no other cause 
of chorea than the presence of oxyurides, and eclampsia has been attributed 
to them, but such a result is exceptional, if indeed the cause be rightly 
assigned. 

Although the caecum is the chosen abode of this worm, and here more 
than elsewhere it exists in its normal state, it is not certain that it produces 
any appreciable symptoms in this part of the intestinal tract. 

The symptoms which render this the most annoying of all the intestinal 
parasites are produced by these oxyurides, chiefly the females, which descend 



774 LOCAL DISEASES. 

into the rectum, where by their active movements they produce intense itch- 
ing. A small number of worms cause little inconvenience, but when many 
are present in the folds of the rectum their crawling produces such intense 
pruritus that the patient can with difficulty remain quiet. Usually this 
symptom is most marked in the early evening, when the child is warm in 
bed. It sometimes causes onanism in the girl as well as boy. This symptom 
may be nearly or quite absent during the day, but it returns so regularly at 
night as to resemble and be mistaken for a periodical nervous affection. So 
eminent a physician as Cruveilhier confesses that he has made this mistake 
of diagnosis. In the female child the oxyuris occasionally passes from the 
rectum to the vulva, producing leucorrhoea. 

In many instances tape-worms exist in children as well as adults who 
thrive and present no symptoms, but in other instances there is more or less 
disturbance of the digestive function, with an uncomfortable sensation in the 
abdomen. This sensation is more noticed after fasting or after the use of 
certain kinds of food, and it is diminished by a full meal. Great hunger and 
a feeling of faintness are also common, according to authorities, but I have 
not particularly remarked them in children. Irregular action of the bowels, 
vomiting and various nervous symptoms, as itching of the nostrils and anus, 
headache, tinnitus aurium, cardialgia, numbness, deafness, blindness, etc. 
have with more or less correctness been attributed to the tape-worm. Cer- 
tainly, such symptoms occasionally arise from this cause, for they cease with 
the expulsion of the worm. 1 Intermittent colicky pains in the umbilical 
region were the only marked symptoms in a child with taenia which I 
recently treated. Since the cysticercus cellulosse is the embryonic form of 
the taenia solium, it is quite possible that individuals possessing the latter 
may be infected from its ova with the former, so that symptoms which have 
been attributed to the intestinal parasite have sometimes been due to the 
encysted embryo. We are unacquainted with the symptoms of the tricho- 
cephalus, if any occur, and this worm is very rare in children. 

Diagnosis. — Bremser long since made the remark — and it has been 
repeated by most writers on diseases of children — that there is no sign or 
symptom which affords positive proof of the presence of intestinal worms 
except the expulsion of one or more. In recent years, however, microscopic 
investigations have revealed a pathognomonic sign — namely, the presence of 
ova in the feces, which indicates not only the nature of the disease, but the 
species of the worm. 

The symptoms and disorders produced by lumbrici may all occur from 
other causes. Still, if several of them be present and a careful examina- 
tion disclose no other cause, the presence of worms should be suspected, 
provided that the child be over the age of two years. The microscope may 
then be used for diagnosis. A little tentative treatment, entirely safe to the 
child, will also determine whether the suspicion be correct. One or two 
doses of medicine, administered under such circumstances, like the surgeon's 
exploring needle may reveal the nature of the disease and indicate the means 
of cure. 

In the case of the oxyuris vermicularis the itching directs attention to 
the anus as the place of the disease, and here the offending entozoa may 
often be discovered by the eye. 

Prognosis. — Intestinal worms produce a fatal result in only a small pro- 
portion of cases. Oxyurides never prove fatal, unless in rare instances through 
convulsions. The manner in which death may be produced by lumbrici has 
already been pointed out. 

In general, when the nature of the disease is ascertained the worms are 
1 Medico-Chir. Rei\, January, 1868. 



INTESTINAL WORMS. 775 

readily expelled by treatment and the patient restored to health. Therefore, 
if there be no complicating disease, the prognosis is good. 

Treatment. — Much injury has been done to children by the use of 
anthelmintics occasionally employed by physicians, but oftener by parents 
before the physician is called. Medicines of this kind are usually irritants, 
and. in many of those diseases which simulate the verminous affection, but 
are distinct from it. there is already an irritated if not an inflamed state of 
the intestinal mucous surface. 

Vermifuges administered under such circumstances obviously do harm, 
and in all acute diseases in which they are not required, even if their action 
be harmless, their employment is to be regretted, since it consumes time, 
which is very precious. It is thus that many lives are lost by the use of 
anthelmintic nostrums which are extensively advertised and which command 
a ready sale, inasmuch as the belief in the presence of worms as a frequent 
cause of disease pervades all classes. 

A safe rule, followed by many physicians — and it would be much better 
if it were general — is not to give anthelmintics unless the child have passed 
one or more worms or their ova be found in the feces, and not then if the 
symptoms seem to be referable to a coexisting disease. In doubtful cases in 
which the symptoms resemble those of worms a purgative dose of calomel 
or calomel and rhubarb may be employed. It will generally bring away one 
or more lumbrici or a mass of ascaris vermicularis if either species of entozoa 
be present. This purgative may be safely employed if there be no previous 
diarrhoea or debility. If after one or two doses and a free purgation no 
worms be passed, anthelmintic remedies should not be given, for it is almost 
certain that none exist. 

A large number of medicines have been employed for the purpose of 
expelling lumbrici. Santonin, the active principle of the European worm seed, 
is one of the best, and is much employed in this country and in Europe. It 
is nearly tasteless ; it may be given in powder spread on bread with butter. It 
is kept in shops in one or two-grain lozenges, with and without calomel. It 
has the advantage of easy administration, and is destructive to both the 
round- and thread-worm. M. Bouchut considers it preferable to all other 
remedies in the treatment of the round-worm. " To children two years of 
age he administers it in doses of ten centigrammes (1.54 grains), and in 
patients above this age the quantity is increased by five centigrammes (0.75 
grain) for every additional year." He gives in addition occasional doses of 
calomel or castor oil. In this country santonin is usually administered in 
one- to three-grain doses once or twice each day, with an occasional purga- 
tive. The purgative is required to aid not only in the expulsion of the worm, 
but also of the ova. In over-doses santonin causes vomiting, diarrhoea, and 
altered vision, so that objects appear yellow, but in medicinal doses it pro- 
duces no unpleasant consequences. Other medicines are preferable if there 
be symptoms of enteritis. Treatment by santonin from two to three days 
suffices. For many years the anthelmintic most employed in this country 
was the pinkroot, the root of the Spigelia marilandica, an indigenous plant. 
It was not only prescribed by physicians, but employed by families as a 
domestic remedy. It is liable to cause, if the dose be large, cerebral symp- 
toms, as vertigo, dimness of sight, spasm of the facial muscles, stupor, and 
even convulsions. These effects less frequently occur if the pinkroot be 
given with a purgative, and it has been customary to administer it in com- 
bination with senna in an infusion. A half ounce of spigelia with an equal 
quantity of senna is macerated for two hours in a point of boiling water and 
then strained. For a child two or three years old the dose is half an 
ounce to one ounce. So popular has this vermifuge been in this country that 



776 LOCAL DISEASES. 

probably a majority of the native-born old people in the States recollect the 
nauseating doses of pinkroot administered by anxious parents. Pharmacy 
now provides us with the same medicine in a more convenient and acceptable 
form, that of the fluid extract: 



R. Fluid ext. spigel., f^j ; 

Fluid ext. senna?, fgss. — Misce. 

One teaspoonful to a child from three to five years. 

The officinal fluid extract of spigelia and senna may be given in the same 
dose as the above. Professor Proctor recommends the addition of santonin 
to this extract : 

R. Fluid ext. spigl. et senna?, 15 j ; 

Santonin, gr. viij. — Misce. 

This is probably the best anthelmintic that can be employed for the destruc- 
tion of the round-worm in uncomplicated cases, and it is also very useful in 
treating the ascaris vermicularis. Chenopodium is also a good anthelmintic. 
It is efficient, and at the same time one of the safest in case the mucous 
membrane be inflamed. If there be abdominal tenderness, with stools too 
frequent and thin or mucous and tinged with blood, I should prefer the 
chenopodium to most of the other vermifuges. To a child of three years 
five drops of the oil may be given three times daily. It may be continued 
for a longer period than would be safe for most of the other vermifuges. 
Twice a week, during its use, a mild purgative should be given, as castor oil, 
rhubarb, or magnesia, unless the bowels are open. It may be given dropped 
on sugar or in a mucilaginous mixture. 

Dr. J. F. Meigs says : " I myself rarely give any other remedy than 
wormseed oil in slight and especially in doubtful cases, unless this has already 
been tried and failed. From my own experience I believe that this remedy 
is all-sufficient in a large majority of the cases that occur in this city, as these 
are almost always of a mild character, and as it not only produces the expul- 
sion of the parasites when they exist, but also acts beneficially upon the 
forms of digestive irritation which simulate so closely the symptoms pro- 
duced by worms. I am persuaded, indeed, that of all the cases that have 
come under my notice in which it seemed probable that worms might be 
present, none were expelled in nearly half, and yet the signs of disturbed 
health have passed away under the use of this remedy." .... -'The follow- 
ing is a very good formula for the administration of this remedy : 

" R. 01. chenopodii, gtt. lx vel f^j ; 

P. g. acacia?, t ^ij ; 

Syrup simplic, :?j ; 

Aq. cinnamom., Jij. — Misce. 

Give a dessertspoonful three times a day for three days, and repeat after several 
days." 

In cases of protracted intestinal disease attended by an increased and 
vitiated secretion from the mucous surface, a state which often gives rise to 
worms, turpentine is one of the best anthelmintics. In fact, in some of these 
cases there is no good substitute for it. For example, a boy of about ten 
years, attended by myself, October, 1864:, had reached or nearly reached the 
fourth week of typhoid fever, when he passed from his bowels a large quan- 
tity of blood. He was previously emaciated and weak, and there had been, 
as is usual in such cases, considerable diarrhoea. The hemorrhage was 





R. Spts. terebinth, rect, 


3y; 




Ol. limonis, 


gtt. v ; 




Mucil. gum. acac.j 






Syr. simplic, 


da. gvj ; 




Aq. anisi, 


Sii-iij 


Dose : 


One teaspoonful every six hours. 





INTESTINAL WORMS. 777 

attended with great prostration, from which, however, he partially rallied by 
the use of stimulants. On the following day an equally severe hemorrhage 
occurred, attended with coldness of the face and extremities and great feeble- 
ness of pulse, so that death appeared imminent. Turpentine was now admin- 
istered every six hours, a few lumbrici were passed, and the case thenceforth 
progressed favorably. The mechanical effect of the lumbrici on the ulcerated 
surface of intestine had probably given rise to the hemorrhage. Turpentine 
may be given in doses of from five to ten minims three times daily to a child 
five years old. Sweetened milk or sugar in powder is a good vehicle for it, 
or it may be given in a mucilaginous mixture : 



-Misce. 



The following formula for the employment of this agent is recommended 
by Dr. Condie : 

R . Mucil. gum acac. , ^ij ; 

Sacch. alb., ^x ; 

Spts. aether, nitr. , ^iij ; 

Spts. terebinth, rect., ^iij ; 

Magnes. calcinat., ^j ; 

Aquse mentha?, ^j. — Misce. 

It is useless to enumerate the many anthelmintic mixtures which, have 
been extolled from time to time. Those mentioned above are the least 
nauseous, and rarely disappoint the practitioner. One other antidote for the 
round-worm should be mentioned, as it has been much used and is efficient 
— namely, cowhage. This consists of the bristles which cover the pods of 
the Mucuna pruriens, a tropical plant. The pods are dipped in plain syrup 
of the ordinary consistence, and the bristles are scraped off with the syrup. 
When enough of the medicine is added to render the syrup of the consist- 
ence of thick honey, it is ready for use. The dose is a teaspoonful every 
morning for three days, after which a cathartic should be administered. I 
have never prescribed cowhage, although it is not unfrequently ordered by 
physicians, and a popular nostrum consists chiefly of it. 

One affected with tape-worm is obviously cured only when the head of 
the parasite is expelled ; but in the majority of cases which I have observed 
the head has not been found in the evacuations, even when the treatment 
had effected a complete cure, as shown by the subsequent history. The 
chain of expelled segments commonly terminates very near the head. This, 
I believe, is the common experience if we trust the friends of the patient 
with the examination of the stools. The physician himself should search 
for the worm's head, the evacuations being preserved. The nurse should be 
directed to add a little carbolic or salicylic acid, and a sufficient quantity of 
water to nearly fill the vessel. The liquid should not be roughly stirred with 
a stick, as physicians are in the habit of doing, since this breaks the worm 
into small portions and renders the inspection more difficult, but it should be 
shaken frequently, so as to detach the segments and head, if it be present, 
from the fecal matter. After it has stood at least five or ten minutes, the 
worm, which has greater specific gravity than water, sinks to the bottom, 
and the upper part should be poured off. This process must be repeated till 
the water is nearly colorless, after which search should be made for the 
fragments, and the head, if present, will be found. 



778 LOCAL DISEASES. 

Since entire expulsion of the tape-worm is effected with difficulty, pre- 
paratory treatment for about forty-eight hours should be employed before 
the vermifuge is administered. During this time the patient should take a 
mild purgative once or twice, and such food, in moderate quantity, should 
be allowed as leaves little residuum, as beef tea, milk, etc., with some stimu- 
lant if the patient feel exhausted. There are three articles of food which 
experience has shown to be especially useful in this preparatory treatment, 
perhaps from a sickening effect which they produce upon the worm — namely, 
salt herrings, onions, and garlic. They may therefore be taken as food in the 
twelve or eighteen hours preceding the employment of the vermifuge, which 
it is ordinarily most convenient to administer in the morning. 

The various taenicides recommended in the books are probably all more 
or less efficient, but the one which has given most satisfaction in the Out- 
door Department at Bellevue, where probably a larger number of these cases 
are treated than in any other place in this country, is the oil of male fern \ 
but it is found necessary to employ a larger dose than is recommended in 
some of the books. For a child of six years the dose employed is one drachm 
in any convenient vehicle, as the syrupus aurantii florum. This should be 
followed in about four hours by a dose of castor oil, which completes the 
treatment. Heller, a high German authority, recommends koosso, or its 
active principle koossin, in the use of which I have had no personal experi- 
ence. The pumpkin-seed has also been employed at Bellevue and elsewhere 
under my direction, but it seems to be less efficient than the oil of male fern. 
If the chain of segments break near the head and the head be not seen, it 
will be necessary to wait two or three months in order to determine whether 
the cure is complete. 

The medical journals during the past year have published and extolled 
the following formula for the treatment of the tape-worm. It is difficult to 
expel the head, and teenicides employed singly so often fail in accomplish- 
ing this result that so powerful a combination of tsenicides deserves consid- 
eration, and perhaps trial. The dose recommended is probably for the adult> 
but a proportionate dose could be given to a child : 

R. Granati corticis radicis, jf ss ; 

Seminarum peponis, Jrj ; 

Pulveris ergotse, gj ; 

Aquse bullient, l^iij • — Misce. 
Fiat infus. 

R. Extracti filicis maris setheris, f^j ; 

01. tiglii. nyj ; 

Pulveris acacise, ^ij. — Misce. 
Fiat emulsionem. 

Mix the emulsion with the infusion and give them at 10 a. m. A full dose 
of Rochelle salts should be given the previous evening, and no breakfast 
taken. 

We should hesitate to administer so powerful a remedy to a child under 
the age of eight years. Perhaps it might be best to recommend one-quarter 
or one-third of the above dose to a child of eight years, and half the dose to 
one of twelve or fifteen years. 

Since the symptoms produced by the oxyuris vermicularis are referable 
chiefly to the rectum, and are caused by the active movements of the worm, 
the prompt and thorough use of enemata, which causes their expulsion, is 
evidently required. Enemata are more effectual if used cool than if warm ; 
and since this worm inhabits the caecum as well as rectum, large enemata 



INTUSSUSCEPTION. 779 

given through a long tube or a large catheter are more effectual, causing the 
expulsion of a larger number of worms than are expelled by small enemata 
employed in the usual manner. Various substances have been used for this 
purpose, as lime-water, table salt in water, turpentine in milk, decoction of 
aloe, decoction of garlic, etc. Heller says : " Simple water would do well 
for this purpose, for in a short time it causes the worm to swell up and burst ; 
but it is not altogether without an injurious effect on the intestinal mucous 
membrane. Hence. Vix recommends a solution of castile soap in distilled 
water or rain-water of the strength of one to two and a half grains to the 
ounce. This has no unpleasant action on the intestinal mucous membrane, 
while at the same time it quickly destroys both the worms and their eggs. 
.... Yix has tested all the medicine in general use in enemata, and has 
found the above solution of castile soap to be the most effectual." The use 
of the enema in the evening, although only a small quantity of liquid be 
employed, so as to wash out the rectum, ensures relief from the itching and 
sleeplessness during the night. 

But it is undeniable that enemata alone do not effect a complete and per- 
manent cure in a large proportion of cases, and hence those affected with 
this worm remain sufferers for years, having only a temporary respite, unless 
medicines be administered by the mouth. Those medicines which produce 
free watery evacuations appear to be the most effectual in dislodging and 
expelling oxyurides. whose attachment to the intestinal surface is not strong ; 
therefore Heller recommends the saline purgatives "joined with copious 
draughts of water." The solution of magnesium citrate found in the shops 
is useful for this purpose. 



CHAPTER XII. 

INTUSSUSCEPTION. 

Intussusception, or the passage of one portion of intestine into another, 
has long been known as an occasional accident. Hippocrates, though debarred 
from the study of morbid anatomy, appears to have had a pretty clear idea 
of this displacement, and he suggested a mode of treatment which has been 
employed till the present time. 

Intussusception without Symptoms. 

This is not properly a disease. It consists in a displacement without any 
other anatomical change. There is, therefore, no obstruction, inflammation, 
or even congestion present, and no symptoms. This form of invagination 
might ordinarily be reduced by the normal peristaltic and vermicular move- 
ments of the intestine. 

Invagination of a portion of the small intestine into the part immediately 
below it is often observed at the post-mortem examination of young infants 
who had presented no symptoms due to the displacement. The invaginated 
mass is usually from half an inch to two inches in length, and as a rule this 
accident is multiple. There may be ten or more distinct intussusceptions at 
distances of a few inches from each other. The simple displacement is 
believed to occur ordinarily at or a short time prior to the moment of disso- 
lution. It has been supposed to be most frequent in those who have died of 



780 LOCAL DISEASES. 

cerebral or spasmodic diseases, but its occurrence is not unusual in other 
pathological states. I have often found it at the post-mortem examination 
of infants who have had subacute or chronic entero-colitis. Heven states 
that he has seen it at the Salpetriere more than three hundred times. Billard 
has seen it especially in infants who have been subject to constipation. Any 
irritant, mechanical or other, which disturbs the regular movements of the 
intestines doubtless may produce it. It has been caused in the rabbit by 
irritating the anus. 

It is not improbable that simple intussusception occasionally occurs tem- 
porarily in children whose health remains good when the regular movements 
of their intestines are disturbed by irritating ingesta or other causes. This 
form of displacement never takes place in the large intestine. Its usual seat 
is the lower part of the jejunum and upper part of the ileum. Since it pos- 
sesses little interest as regards pathology, and none whatever as regards 
symptomatology and therapeutics, it may be ignored in our description of 
intussusception. 

Intussusception with Symptoms. 

Intussusception, or invagination, is one of the most painful and danger- 
ous of human maladies, but fortunately it is not very frequent. I have the 
records of 52 cases occurring in children in addition to the records of sev- 
eral cases more recently observed. From these the facts contained in this 
chapter are chiefly derived. The patients were under the age of twelve years. 

Previous Health. — In 34 of the 52 cases the state of the health pre- 
viously to the invagination was recorded. From the following table it is seen 
that one-half, or 17, were previously well, the remaining half suffering from 
some disease or derangement : 

Previous Health. 



Age. Good. Disease or Derangement. 

One year or under 15 8 

Over one year _2 9 

17 17 

MM. Rilliet and Barthez, whose views in reference to intussusception are 
derived from the examination of the records of 25 cases, state that the pre- 
vious health is ordinarily good, and the intussusception is therefore primary. 
Their remark, according to the above statistics, is seen to be correct as regards 
patients under the age of one year, but incorrect for those over that age. 

Most of the 17 who had previous ill-health had diarrhoea, dysentery, or 
constipation, or diarrhoea alternating with constipation. Of those otherwise 
affected, 1 had thread-worms, 2 obscure abdominal pains, 1 nausea and vomit- 
ing, and 1, whose age was four months, had had symptoms of invagination 
when ten weeks old, which soon passed off. It is seen that the pre-existing 
affections were ordinarily such as would be likely to accelerate the movements 
of the intestines and at the same time render them irregular. 

Causes. — The above statistics, therefore, show that intussusception is 
often preceded by disease or functional derangement of the intestines. The 
two opposite conditions — namely, constipation and the diarrhoeal maladies — 
so often precede the displacement that they must be regarded as common 
causes. Another probable cause is intestinal worms, which by their mechani- 
cal action stimulate the intestines. They were present in 3 of the 52 patients, 
though 2 of the 3 seemed well till the occurrence of the intussusception, but 
the other patient had complained of irritation at the anus, and ascarides had 
been found on examination. 



3 were 3 months old. 


2 " 4 


ti a 


3 " 5 


a u 


5 " 6 


a (i 


1 was 7 


u a 


1 " 8 


n a 


3 were 9 


a (i 



IXTUSSUSCEPTION. 781 

The use of irritating and indigestible food is an occasional cause. Thus, 
some who have had intussusception have been in the habit of eating fruits, 
candies, and pastries freely. Such ingesta may be an immediate cause by 
their irritating effect, or a remote cause giving rise to diarrhoea, which in turn 
produces intussusception. 

Sex is a predisposing cause, since male patients are largely in excess. 
Of the 25 cases collated by Rilliet and Barthez, all but 3 were boys. In 
our own collection the sex of 34 of the patients was recorded, and of these 
23 were boys. 

In rare instances external violence is the apparent exciting cause. One 
patient received a severe contusion of the abdomen two years before death, 
and from this time continued to complain at intervals of pain in the bowels. 
One writer also mentions the case of a child nine years old who received a 
blow from a comrade at school, and from this time had alternately diarrhoea 
and constipation till the invagination commenced. Rilliet and Barthez also 
relate the cases of two children who were taken suddenly with invagination 
when their parents were tossing them in their arms. 

Age. — Of the 52 cases embraced in our statistics, the ages were as 
follows : 

1 was 10 months old. 
1 " 11 " " 

1 « 12 " 

2 were from 1 to 2 years old. 
8 " " 2 " 5 " " 
8 " " 5 "12 " " 

3 not given. 

Therefore, no cases occurred under the age of three months ; 23 cases were 
between the ages of three and six months, or nearly one-half of the entire 
number ; 8 between the ages of six months and one year ; and only 18 between 
the ages of one year and twelve. These statistics correspond, in the main, 
with those of Rilliet and Barthez, in whose collection of 25 cases no one was 
under the age of four months. Leichtenstern l says : " Half of all invagina- 
tions, according to my statistics of 473 cases, occur during the first ten years. 
The first year after the third month is remarkable for a special frequency — 
one-fourth of all intussusceptions." 

The great liability to intussusception in infancy is due partly to the ana- 
tomical character of the intestine in this period of life, and partly, doubtless, 
to the fact that there are more frequent irregularities in the intestinal move- 
ments than in older children. In the infant the walls of the intestines are 
thin, the mucous and muscular coats and the connective tissue being much 
less developed than in those that are older ; the mesentery and mesocolon 
have also greater depth as compared with the same in other periods of life, 
except the mesocolon at the points where it passes over the kidneys, in which 
places it is very short or even in some cases nearly absent. Moreover, the 
space occupied by the large intestine, in which part of the digestive tube 
intussusception commonly occurs, is much shorter relatively to the length of 
the intestine than in those that are older. In about thirty measurements 
which I have made of the length of the large intestine and the space occupied 
by it the latter was found, on the average, about one-third that of the former, 
which of course necessitates doubling of the intestine on itself. These pecu- 
liarities of structure in the infant obviously favor the occurrence of intus- 
susception. 

Seat and Pathological Anatomy. — While intussusception occurring 
1 Ziemsseri's Encyclop. 



782 LOCAL DISEASES. 

without symptoms is usually multiple, that form which occurs with symp- 
toms is ordinarily single. Two exceptional cases which I observed will be 
presently related. In one of the cases embraced in the statistics an invag- 
ination occurred with symptoms, and coexisting with it was another in 
the small intestines apparently without symptoms and quickly reduced by 
handling. 

While intussusception without symptoms occurs in the small intestine, 
the seat of intussusception with symptoms is, with occasional exceptions, the 
colon. The colon constitutes the entire invaginated mass, or else and more 
frequently it forms the exterior, while the incarcerated portion consists wholly 
or in part of the ileum. 

Intussusception in the Small Intestines. 

Bouchut says : " M. Rilliet states in a recent treatise that in infancy the 
intestinal invagination is always accomplished at the expense of the large 
intestine, and that there is never invagination of the small intestine. This 
is incorrect. I have observed the small intestine invaginated in the adjacent 
inferior part. Taylor has reported a case of this kind in a child twenty 
months old who died after an attack of acute peritonitis. M. Marage has 
seen another case in a child thirteen months old, who recovered after having 
voided the invaginated portion furnished with two of those diverticula so 
frequent in the small intestine of the foetus." 

But, from all that appears, the case reported by M. Marage may have 
been, and probably was, an example of the common form of intussusception — 
to wit, the prolapse of the ileum into the colon. In Mr. Taylor's case the 
invagination was really of the ileum into the colon, although a small por- 
tion of the ileum next to the valve had not been inverted, so that it con- 
stituted a little of the exterior of the mass. 

Nevertheless, Bouchut is correct in stating that irreducible and fatal 
intussusception may occur in the small intestines. Probably the displace- 
ment is at first of the simple variety, but, continuing and increasing in 
extent, its return becomes impossible. The positive statement of so great 
an authority as M. Billiet, that intussusception with symptoms does not 
occur in the small intestines, justifies the publication of the following cases, 
which establish the fact that there are instances, though not frequent, in 
which the displacement does have this location : 

Case 1. — This patient's health had been uniformly good, and nothing unusual 
was observed in his condition till the age of four and a half months, when he 
became restless, as if in almost constant pain, with occasional exacerbations. 
Castor oil was prescribed, which operated freely, and then the following mixture : 

R. Magnes. calcinat., £)j ; 

Tinct. opii camphorat., ^ij ; 

Tinct. asafoet. , ^ss ; 

Aq. anisi, ^j. — Misce. 

Dose : Ten to twenty drops, repeated according to the pain. 

These remedies failed to give relief, as did also chloroform given in doses of 
two drops. After two or three days another set of symptoms arose, those cha- 
racteristic of pneumonia — to wit, hurried respiration, accelerated pulse, short, 
suppressed cough, and expiratory moan. He was treated with the oiled-silk 
jacket and mild counter-irritation, and took an expectorant mixture containing 
ammonium carbonate. In a few days the pulmonary disease was evidently sub- 
siding, but the pain in the abdomen, with occasional exacerbations, continued. 
His countenance was pallid and bore an expression of suffering. There was no 
distention or tenderness of abdomen and no abdominal tumor. He took little 
nutriment and seldom vomited. In the last part of his sickness the dejections 



INTUSSUSCEPTION. 



783 



were scanty, and the last three days his stools consisted mainly of mucus and a 
little blood. The pain seemed to be growing less when he was seized with con- 
vulsions, and died the same day, precisely two weeks from the commencement 
of his sickness. 

Sectio Cadaver. — Head not examined ; body slightly emaciated ; mucous mem- 
brane of trachea and bronchial tubes vascular ; posterior portion of the lower lobe 
of each lung solid, of greater specific gravity than water, and allowing only partial 
inflation ; it was in the second stage of pneumonia. Stomach, duodenum, jejunum, 
healthy. In the upper part of the ileum was an intussusception two-thirds of an 
inch long, presenting no trace of inflammation either within or around it, and its 
vascularity, when it was examined externally, did not seem notably increased. 
Above the intussusception the intestine was empty •, below it, and chiefly in the 
small intestine, was a dark-colored substance, evidently blood, and giving in a few 
hours the offensive odor of decaying animal matter. There was a passage through 
the intussusception at least two or three lines in diameter, as shown by a probe. 
The intussusception sustained the weight of sixteen inches of the intestine, and it 
would have apparently sustained considerably more. The remaining organs were 
healthy. 

Case 2. — F. S , a female infant four months old, was treated at the New 

York Infant Asylum in June and July, 1865, for entero-colitis, the usual epidemic 
of the summer season. The following records show the state of the bowels imme- 
diately before her death : 

June 29th : Has five or six stools daily. 30th : Two stools in twenty-four hours. 
July 1st: Had two stools since the last record; no vomiting. 3d: Four stools in 

Fig. 212. 




last twenty-four hours. 4th : The diarrhoea continues, as before ; the stools about 
four daily. On the 6th of July she died. 

Her pulse during the time in which these records were taken generally num- 
bered about 128 per minute. She was much emaciated, and the day before death 
she frequently struck her head with her hand. The medicines employed were 
mainly alkalies and astringents. 

Sectio Cadaver. — Parietal bones united ; serous effusion over the convolutions 
of the brain, under the arachnoid ; occipital bone depressed ; commencing at a point 
about two feet below the stomach were four intussusceptions two or three inches 
from each other. The invaginated masses were from one to one and half inches in 
length, and three of them were found to be very vascular in their interior. Above, 
between, and immediately below the intussusceptions the intestine was healthy. 
One of the invaginations was tested by weight, and was found to sustain a foot 



784 LOCAL DISEASES. 

and a half of intestine, and would have sustained more. Water poured above 
these intussusceptions escaped through them very slowly ; no fibrous exudation - y 
descending colon vascular and thickened and solitary glands enlarged. 

The irreducible character of the intussusceptions in the above cases was 
shown by the fact that they sustained weights which doubtless produced 
greater traction than that exerted by the intestine in its normal action. 
That the displacement existed prior to the moment of death was shown by 
the symptoms in one of the cases and by the anatomical changes in both. 
In one the capillaries of the incarcerated mass were ruptured during the 
last days of life, so as to produce sanguineous stools, while in the other 
there was intense congestion of the invaginated mucous membrane, and 
that portion of this membrane which was adjacent, but not engaged, was 
healthy. 

In both patients the symptoms were less severe than in ordinary cases, 
and they came on more gradually, for the invaginated intestine was not com- 
pletely closed, so that it allowed the passage of fecal matter in one till the 
close of life, and in the other till near its close. At both of the autopsies 
water poured into the intestines above the invaginations passed slowly through 
them. 

Intussusception in the small intestines in the infant, commencing as the 
simple form, may become irreducible, and yet, remaining pervious, may con- 
tinue for weeks without giving rise to severe or dangerous symptoms. The 
following case was an example of this : 

Case 3. — Male child, died at the age of nineteen months, the last eleven of which 
he was under observation. The mother states that he had never been well since the 
age of one month, and that there had been little variation in the symptoms of his 
disease. During the period in which he was under observation he was ordinarily 
fretful, and frequently seemed to be in considerable pain. His stomach during this 
whole time was so irritable that he rarely took more than three or four spoonfuls 
of nutriment without vomiting. There was usually more or less diarrhoea, but no 
tenderness or distention of abdomen. He became slowly but gradually more ema- 
ciated, and finally died in a state of extreme emaciation and exhaustion. He had 
no convulsions, and was conscious to the last. 

Sectio Cadaver. — Brain not examined ; lungs healthy, except a circumscribed 
portion which was inflamed at the summit of the right lung ; liver small and almost 
destitute of oily matter, as shown by the microscope. In the jejunum, about two 
feet below the stomach, was an intussusception two inches long, the intestine form- 
ing which seemed to have undergone no structural change. Above the intussuscep- 
tion the intestine was of small calibre, and entirely empty and pale; below the 
intussusception the intestine was somewhat larger than above, but it seemed quite 
healthy. The invagination was sufficiently pervious to allow water to pass through 
it, and it readily sustained the weight of two feet of intestine. From eight to ten 
inches below this intussusception there was another, which was immediately drawn 
out the moment the intestine was disturbed. The other abdominal viscera were 
healthy. 

There is uncertainty as to the duration of the intussusception in the 
above case, but the symptoms indicated that it existed a considerable time 
prior to death. There was no strangulation, nor indeed any appreciable 
anatomical alteration in the coats of the intestine, but the fact that the 
invaginated mass sustained two feet of intestine and required considerable 
traction for its reduction shows that it was not a case of simple displace- 
ment occurring at the moment of death and without symptoms, but was an 
example of the variety with symptoms. 

Intussusception in the Large Intestines. 

In most cases of intussusception occurring in infancy and childhood the 
ileum is invaginated in the colon or the first part of the colon is invaginated 



IXTUSS USCEPTION. 785 

in the part succeeding it. Intussusception not infrequently begins in the 
prolapse of the ileum through the ileo-caecal valve, in the same way that pro- 
lapse of the rectum occurs through the sphincter ani. If death take place 
early, only a small portion of the ileum may have passed the valve. If the 
case' be protracted, the tenesmus brings down more and more of the ileum, 
with its accompanying mesentery. The constriction of the valve, which acts 
as a ligature, soon prevents the further descent of the ileum ; and, the tenes- 
mus continuing, the next step in the displacement is the inversion of the 
caput coli. which is drawn into the colon by the descending mass, and unless 
the case terminate by sloughing or death, the ascending and transverse 
portions of the colon are successively invaginated. The records show that 
intussusception occurs as above stated in a large proportion of cases. In 
one case among those which I have collated the invagination began a few 
inches above the valve, so that the ileum constituted a small portion of the 
exterior of the mass. Occasionally the caecum is the part primarily inverted 
and invaginated, and, descending along the colon, it draws after it the ileum, 
which sustains its natural relation to the ileo-caecal valve. When this occurs 
the caecum is found at the lower end of the mass, and two orifices are 
observed, one leading through the valve and the other into the appendix 
vermiformis. These two forms of invagination — that in which the ileum, 
passing through the ileo-caecal valve, successively inverts and draws after it 
the caput coli and the divisions of the colon, and that in which the caput 
coli is primarily invaginated, and, descending along the large intestine, in- 
verts the latter and draws after it the ileum — constitute the vast majority 
of cases of this disease in the first years of life. 

I have notes of 45 fatal cases occurring under the age of twelve years 
in which the portion of intestine first displaced is recorded. In 4 of these 
the displacement was entirely in the small intestine, involving in no way the 
colon ; in 38 cases it commenced either by prolapse of the ileum through the 
ileo-caecal valve or by the inversion of the caecum into the ascending colon, 
there being perhaps not much difference in the relative frequency of these 
two modes ; in one case the invagination was confined to a segment of the 
transverse colon, in another to a segment of the descending colon, and in the 
remaining case to the lower part of the descending colon and the upper part 
of the rectum. In three instances the invaginated mass itself became invag- 
inated, producing an intussusception of great thickness, and necessarily 
fatal. 

Intussusception is sometimes attended by so little constriction of the 
incarcerated portion that it remains pervious. In such a case life may be 
protracted for weeks or even months without reduction of the displacement 
or any material change in it, the passage of fecal matter being sufficiently 
free for the maintenance of life. Death finally occurs in a state of exhaus- 
tion. Thus in one instance a child four months old lived six weeks after the 
symptoms of invagination commenced, and seventeen days " with a portion 
of the bowel protruding from the anus." It was found at the post-mortem 
examination that part of the ileum had descended through the entire colon, 
and had remained pervious. In a case related by Dr. Worthington 1 symp- 
toms of intussusception were present for seven months before death, and 
during the last six weeks of life the invaginated intestine protruded fre- 
quently from the anus, and was replaced by the mother. In this case " the 
caecum was inverted, and, descending through the colon to the lower portion 
of the rectum, carried with it the ileum and the entire colon except the last 
ten or twelve inches." In another case the symptoms indicated a continu- 
ance of the disease for three, if not eight, months. But such cases are ex- 
1 Amer. Journ. of Med. Sci., for January, 1849. 
50 



786 LOCAL DISEASES. 

ceptional. Ordinarily, as the intestine becomes invaginated its mesentery 
or mesocolon is also invaginated and its veins compressed. The pathological 
state of the incarcerated mass soon becomes that of intense congestion. In 
infants, usually in a few hours, so great is the distention of the capillaries 
that they give way, blood escapes into the intestine, and passes from the 
bowels in scanty motions. On examining the invaginated intestine after 
death, if gangrene have not occurred, it is found of a uniformly intense red 
color, sometimes resembling to the naked eye a long and firm clot of blood. 
In those who die early no traces of inflammation are seen, but in more pro- 
tracted cases the attrition between the serous surfaces excites local peritonitis. 
In none of the fifty-two cases which I have collated, in which post-mortem 
examinations were made, did the inflammation extend more than a few lines 
beyond the invagination. Usually the intestine forming the exterior of the 
invaginated mass is much drawn together or puckered. In one case treated 
by myself the entire large intestine which formed the exterior of the mass 
was compressed within a space of six inches or less, since about twelve 
inches of the ileum, doubled on itself, lay within the entire colon and pro- 
truded from the anus, the only part of the large intestine which was inverted 
being the caput coli. In one case six or seven inches of the ileum, which 
formed a portion of the exterior of the mass, were compressed within the 
space of one inch. 

The abdomen, at first of natural fulness and soft, usually becomes more 
and more distended till the close of life ; but in case of much vomiting the 
distention is moderate. The fulness is due to gas and fecal accumulation 
above the invagination. The portion of the intestine below the displacement 
is ordinarily empty, except that in the infant it commonly contains mucus, 
mixed with more or less blood which has escaped from the capillaries of the 
strangulated mass. 

There are few anatomical changes in this disease which do not arise 
directly from the intussusception, and are therefore located either within the 
mass or in its immediate vicinity. In those who recover by the process of 
sloughing the cicatricial contraction may give rise to symptoms and lesions 
of greater or less gravity. Thus the late Sir James Y. Simpson examined a 
child aged nine years who recovered with loss of ten inches of intestine, 
and, at the meeting of the Medical Society ] before which the specimen was 
presented, he remarked that there was unusual distention of the cutaneous 
veins of the patient, due probably to such compressions of the ascending 
vena cava by the cicatrix that the venous circulation was obstructed. Mr. 
Charles King 2 relates the case of a child aged six years who on the eleventh 
day of the disease voided the caecum and a part of the colon. Two days 
subsequently pulsation ceased in the left leg, and all that part below the 
patella became gangrenous. The patient gradually recovered with loss of 
the leg. The cause of this unfortunate sequel was doubtless compression 
from the cicatricial contraction around the artery which supplied the leg, and 
probably the formation of a thrombus. Dr. F. Bush 3 relates a case in which 
he was enabled to observe the extent and appearance of the cicatrix. The 
patient, aged twelve years, discharged from the bowels fifteen to eighteen 
inches of the ileum on the eighth day of the intussusception, after which 
convalescence was rapid. Fourteen weeks later the child died from tj'phus 
fever, and at the autopsy '-traces of the diseased bowels were visible by a 
contraction and puckering where the slough had taken place and the parts 
united." But, fortunately, in most instances when the intestine sloughs and 
the child survives no serious or permanent injury results from the cicatriza- 

1 Trans. Medico-Chir. Soc. Edin. 2 London Lancet, for 1854. 

3 Load. Med. and Phys. Journ., for December 18, 1823. 



IXTUSSUSCEPTION. 787 

tion. The cicatrix stretches little by little and accommodates itself to the 
surrounding parts. 

Symptoms. — The symptoms vary according to the age of the patient 
and the degree of strangulation. Pain in the abdomen, usually paroxysmal, 
is among the first and is one of the most conspicuous symptoms. It is often 
severe, resembling the pain of hernia, and abating only with the failing 
strength of the child. After the first few days, if inflammation arise, the 
pain is continuous, though more severe in paroxysms. At first pressure upon 
the abdomen is tolerated, but afterward there is tenderness. This is due to 
the inflammation which occurs in and around the invaginated mass, and it is 
therefore confined to the part of the abdomen in which the tumor lies. At 
this point also the abdomen is more full than elsewhere, and not infrequently 
the physician can feel the invaginated mass and detect its exact location and 
approximately its extent. Sometimes, at an early period as well as late, 
cerebral symptoms occur, as in a case related by Dr. Cogswell 1 which ter- 
minated in convulsions and death on the second day. Convulsions are, how- 
ever, comparatively rare, and the mind is generally clear till the last moment. 
In infants the countenance in the intervals without pain, in the first stages of 
the complaint, is often placid and not indicative of any serious disease, but in 
older patients constant and severe local symptoms, referable to the intus- 
susception, commence early. At an advanced period, whatever the age, the 
countenance becomes anxious and haggard, the eyes hollow or sunken, the 
body loses its plumpness, and, if the case be protracted, becomes emaciated. 

Vomiting is rarely absent ; in 39 out of 47 cases it is stated to have been 
present ; in 7 cases there is no record of this symptom, while it is recorded 
absent in only 1 case ; but in this case, the records of which are very meagre, 
death occurred on the second day. The vomiting becomes stercoraceous in a 
few days, and it ordinarily continues with greater or less frequency till the 
period of collapse. It relieves partially the distention. 

The appetite is impaired and often entirely lost. Infants at the breast 
commonly nurse, however, for several days, probably from thirst rather than 
hunger. 

In most patients one natural evacuation occurs from the bowels after the 
intussusception commences, and then obstinate constipation succeeds. This 
evacuation consists of the excrementitious matter below the invagination. 
In children under the age of one year scanty motions of blood mixed with 
mucus begin to occur in a few hours. Of 27 children under this age, I find 
that 24 had such evacuations, occurring in most of them several times in the 
course of the day ; in 2 of the 27 there is no record of this symptom, but in 
the remaining case it is stated to have been absent. Scanty evacuations of 
blood unmixed with fecal matter have been considered pathognomonic of 
intussusception in the infant, and we see the ground for such belief ; but in 
exceptional instances the invaginated mass is partly pervious, and although 
the dejections may contain blood, they are also excrementitious. In our col- 
lection of cases are 3 examples of this in infants under the age of one year. 
One has already been referred to. In this case there was the rare anomaly of 
so large an opening through the ileo-csecal valve as to allow not only prolapse 
and descent of the ileum through the entire colon, so as to protrude six inches 
from the anus, but also fecal passage through it daily. 

In children above the age of one year the capillaries of the invaginated 
intestines are not so frequently ruptured as under this age, and sanguineous 
evacuations are therefore less common. I have records of 19 cases between 
the age of one year and twelve, in only 6 of which it is stated that there were 
bloody motions, and in these the blood was not passed frequently, nor even 
1 London Lancet, for July, 1853. 



788 LOCAL DISEASES. 

in some cases daily, as in infants, nor in so pure a state, unless in 2 cases, 
the records of which are not explicit on this point. Two of these 6 patients 
passed moderate bloody evacuations after protracted periods of constipation, 
1 had fecal discharges with the blood through the entire sickness, and in 
1 blood was passed at first, but finally the stools were entirely fecal. 

In those above the age of one year obstinate constipation was ordinarily 
present, no dejections, either bloody or fecal, occurring for several days ; but 
there were a few exceptions. In 3 cases the bowels were relaxed. The 
ileum in these 3 had descended through the entire colon or the larger part 
of the colon, and, being pervious, the feces escaped from the anus without 
detention in the large intestine or with detention only in its lower portion, 
and were therefore liquid. 

Tenesmus is another symptom. It is not always present, but in a large 
proportion of cases, even when the invagination is in the upper part of the 
large intestine, it is a frequent and distressing symptom. It often does not 
commence till there is a considerable amount of displacement, and it ceases 
when the strength is much reduced. 

The temperature of the surface is normal in the commencement of intus- 
susception ; but finally, as febrile reaction symptomatic of the inflammation 
comes on, it rises and continues above the healthy standard till the intestine 
sloughs or till the stage of collapse occurs which ushers in death. The pulse, 
especially in the infant, is tranquil at first, but, whatever the age, it soon 
becomes accelerated from the paroxysms of pain, and subsequently from the 
inflammation which occurs in the invaginated mass. There is no disturbance 
of respiration, except that it is somewhat hurried from the fever and from 
the pain felt in advanced cases on full respiration. 

It will be seen that the symptoms vary in certain particulars under the 
age of one year from those occurring over that age, but differences in the 
symptoms depend more on the degree of invagination and constriction than 
on the age and exact location of the disease. 

Diagnosis. — The diagnosis of intussusception is not, in general, difficult, 
except at its commencement. When the inversion has reached that degree 
at which obstruction occurs, the symptoms are, in most cases, such that the 
disease can be readily diagnosticated. In the cases whose records I have col- 
lated a correct diagnosis was made with few exceptions, and at an early period. 
In the infant the disease for which intussusception is most frequently mis- 
taken is dysentery, on account of the tenesmus and the muco-sanguineous 
stools. In certain of the reported cases this mistake was not rectified until 
it was ascertained that purgatives produced no fecal evacuations. 

The symptoms which are commonly present, and which indicate the 
nature of the disease, are obstinate constipation, vomiting, paroxysmal pain 
referred to the seat of the disease, and tenesmus. In the infant also scanty 
evacuations from the bowels of mucus and blood or of pure blood are, as we 
have seen, an important diagnostic sign. It should be borne in mind, how- 
ever, that in exceptional cases the displaced bowel may remain pervious, and 
the usual symptoms which possess diagnostic value therefore be absent. 
There may be no vomiting or tenesmus, and diarrhoea may even occur in place 
of constipation, as in the cases related above. As an aid to diagnosis it 
should be stated that, whatever the age of the child affected with intussus- 
ception, clysters are often administered with difficulty, and are quickly and 
forcibly returned, on account of the resistance opposed by the invaginated 
mass. We have stated above that the seat and even extent of displacement 
can be ascertained in a large proportion of cases by digital examination of 
the abdominal walls. The tumor can be felt hard, elongated, and tender on 
pressure, so that the diagnosis is clear. If the invagination have extended 



IXTUSSUSCEPTIOX. 789 

to the lower part of the large intestine, it can usually be discovered by an 
examination per rectum. 

Duration. — In the following table the duration of the intussusception 
in 49 cases is given as nearly as it can be ascertained from the records : 



2 died the 1st day. 



6 

4 


c< 


" 2d 
" 3d 


2 


(( 


" 4th 


5 


(( 


" 5th 


2 


({ 


" 6th 


2 


u 


" 7th 



1 lived over a week. 



1 died the 8th day. 

1 " " 10th " 

1 " " 14th " 

1 lived nearly a week, the exact 

time not being given. 
1 lived six weeks. 
3, time of death not given. 
7 recovered. 



In 2 of the 3 cases in which the duration is not stated the patient lived much 
longer than the usual period. One of these 2, a girl of six years, having 
eaten raw carrots, was seized with pain in the abdomen, which lasted eight 
months, when she died. During the last three months she passed mucus 
and blood. In this case the caecum had descended to the anus, drawing with 
it the ileum, which remained pervious. The symptoms indicated the con- 
tinuance of the invagination for three months, if not eight. The other 
patient was a boy aged three years and four months, who complained of pain 
in the abdomen for many months, and occasionally vomited. During the last 
six weeks of his life all the phenomena of invagination were present. In 
this case also the inverted caput coli had descended the entire length of the 
colon, and at the autopsy it lay in the rectum. 

In West's Treatise on Diseases of Children (5th ed., 1866, p. 504) it is 
stated that death in this complaint always occurs within a week. The above 
statistics, however, show that there are exceptions to this statement, although 
a large majority do die within the first seven days. In 33 of the cases 
embraced in my statistics death occurred within the first week, and in no 
fatal case in which strangulation was complete was life prolonged beyond the 
eighth day. In these cases of complete strangulation the average duration 
was 3.7 days, and the largest number of deaths occurred on the third day. 
Death on the first day is rare, but it occurred in two of the cases embraced 
in my statistics. Death at so early a period usually takes place in convul- 
sions and coma. 

Prognosis. ^Intussusception is in its nature so grave an accident that the 
physician called to a case should always explain its gravity to the friends. 
But, while death is the common result, there are three different modes of 
termination in which life is preserved : First, the reduction of the incarcerated 
intestine, with immediate relief. There can be no doubt that it is possible for 
intussusception, when recent, to be reduced by the unaided action of the 
bowels, in the same way as the common, simple intussusception in the 
jejunum and ileum or as hernia is reduced, through the vermicular action 
of the intestines ; for sometimes, as in Dr. Coggswell's l case, the patients at 
some previous time have experienced the same symptoms as those which 
accompanied the attack, and which subsiding they remained for a time in 
perfect health. This termination is probably rare if the symptoms be 
sufficiently marked to necessitate treatment. Again, the intussusception may 
be cured by early and well-applied treatment. The physician often succeeds 
in reducing the displaced intestine, even if the intussusception be in the 
upper part of the colon, if he be called sufficiently early and employ the 
proper measures. 

A second mode of favorable termination is alluded to by certain foreign 
1 London Lancet, July, 1853. 



790 LOCAL DISEASES. 

writers. The intussusception continues for a considerable period with the cha- 
racteristic symptoms, and then, as Bouchut expresses it, " the vomitings grad- 
ually cease, the intestinal hemorrhage disappears, the strength returns, and 
the health becomes restored without the expulsion of fragments of the intes- 
tine/' What changes the displaced intestine undergoes in these protracted 
cases, which gradually recover without sloughing, have not been clearly ascer- 
tained, although they have been the subject of conjecture. According to 
Billiet, a large proportion of favorable cases terminate in this manner. It 
does not appear, however, from the statistics which I have collected that this 
is a common mode of recovery. The clinical history of intussusception estab- 
lishes the fact that in a large majority of protracted cases there is either death 
or the third mode of favorable termination — namely, by sloughing. 

But we cannot reasonably expect recovery in young children through 
sloughing and the expulsion of the intestine, since few have the requisite 
strength for so tedious and exhaustive a process. The youngest child that 
recovered in this way, so far as I have been able to ascertain, was an infant 
thirteen months old, whose case was reported by M. Marage. With the 
exception of this case the youngest was a boy aged five years. The older 
the child the greater, of course, the power of endurance and the better the 
prospect of recovery. Of the 52 cases whose records I have collated, 7 
recovered by the sloughing and expulsion of the mass. These children were 
of the ages of five, six, six, nine, eleven, twelve, and twelve years. The sep- 
aration of the invaginated mass occurred in six of these between the sixth 
and twelfth days, with an average of nine and a half days. In the remain- 
ing case the time is not given. If, then, the patient can be carried through 
the first week without too much exhaustion, discharge of the slough, reopen- 
ing of the bowels, and ultimate recovery may possibly be the result. 

But in those cases in which the intussusception remains open, so as to 
allow the passage of fecal matter, recovery is improbable unless the displace- 
ment be diagnosticated early and properly treated. If the intussusception 
continue, it becomes greater and greater from the absence of strangulation. 
Without inflammation and with little or no congestion of the displaced por- 
tion, and without the severe symptoms which occur in ordinary cases, the 
patient wastes away, having irregular evacuations and more or less abdominal 
pain, and finally dies in a state of emaciation and weakness. In the early 
stage of this form of displacement it is not improbable that injections or 
inflation, employed with sufficient force, will give relief, but if the early 
period pass without such treatment, cure is impossible by the ordinary 
methods. It is in such instances especially — to wit, those in which the dis- 
placement occurs without strangulation or inflammation, and in which fecal 
matter passes through the displaced mass more or less freely — that laparotomy 
is justifiable, and is likely to give relief when injections and inflation have 
been employed in vain. Jonathan Hutchinson's successful performance of 
this operation in a child of two years who had this kind of displacement is 
known to most readers. 1 

The prognosis is most favorable when the displacement occurs in the 
lower part of the large intestine, for its reduction is then comparatively easy. 
An interesting case of this kind was observed and treated by Drs. O'Dwyer, 
Beid, and myself in the New York Foundling Asylum in 1875. The child 
was a female aged two years, and had had previous good health. The 
invaginated mass protruded like a prolapse about four inches outside of the 
anus. It was cold, considerable hemorrhage had occurred from it, and the 
infant seemed in collapse. When the mass was returned so far as it could 
be carried within the pelvis by the index finger, the lower end of it could 
1 London Lancet, November 22, 1873. 



INTUSSUSCEPTION. 791 

still be felt like an os uteri. It protruded four or five times within twenty- 
four hours, but by replacement so far as possible with the fingers and the use 
of simple water injections, with the hips elevated, it was finally permanently 
reduced, and. with the use of stimulants, she soon fully recovered. 

Mode of Death. — This is different in different cases. It sometimes 
occurs from collapse. At a meeting of the New York Pathological Society, 
held December 10, 1873, I presented a specimen showing intussusception 
occurring about one foot above the ileo-csecal valve in an infant aged thirteen 
months. On the day before its death, its previous health having been good, 
it seemed ill, and vomited once or twice, but did not appear to be in pain. Ifc 
had two evacuations from the bowels, of the usual appearance, in the latter 
part of the day. On the following morning it was unexpectedly in collapse, 
and died within about twenty-four hours from the commencement of the sick- 
ness. At the post-mortem examination the cranium was not opened, but all 
the organs of the trunk were found normal except the intussusception. The 
mass involved in the displacement measured two and a half inches in length 
and was slightly crescentic. The mucous membrane above and below it had 
the normal appearance, as had that of the external or incarcerating portion of 
the mass, while that of the incarcerated part was deeply injected. Water 
poured into the intestine above the invagination was wholly arrested by it. 1 
But in the majority of instances death occurs from asthenia, which comes on 
gradually, but increases rapidly in consequence of the pain, vomiting, and 
imperfect nutrition. Children dying in this way may have convulsive 
movements more or less marked, but the prevailing characteristic as death 
approaches is extreme exhaustion. In exceptional instances the life of the 
sufferer is cut short by convulsions before the stage of exhaustion is reached. 
Thus a child aged three years, whose case was reported by Dr. Isaac Thomas, 2 
and another, aged two years, whose case was reported by Dr. Coggswell, 3 died 
in convulsions on the second day. 

Treatment. — It is unfortunate in cases of intussusception that the time 
in which treatment can be of most service is likely to pass by before the true 
condition of the intestine is detected. Invagination being comparatively rare, 
the patient is generally on the first day treated for colic or dysentery or some 
other common affection of the bowels, and it is often not till the second day, 
when the intestine has become incarcerated, that the physician accurately 
diagnosticates the disease. The purgative medicines often given in the 
commencement injure the patient. In fact, both reason and experience 
teach us the impropriety of using purgatives in this complaint. Cathartic 
remedies act as a vis a tergo, and may cause still further descent of the in- 
verted intestine. Yet such powerful agents of this class as quicksilver have 
been employed. It was administered in two doses of one ounce each in one 
of the cases embraced in my statistics, but none of the mineral passed the 
bowels. At the post-mortem examination a considerable part of it was found 
in small globules, coated with a black layer consisting of the sulphuret or 
black oxide of mercury, in the intestine above the intussusception. It need 
not be added that the case was speedily fatal. 

The proper treatment of intussusception consists in attempts to reduce 
the displacement by pressure from below. The pressure may be applied 
either by liquid injections into the rectum or by inflation of the lower intes- 
tine by air or gas. 

Injections should be made with lukewarm water, for cold or hot water 
may cause contraction of the muscular fibres of the intestine and increase 
the constriction. The child should be placed in bed or in the nurse's lap. 

1 New York Medical Record, April 1, 1874. 2 Amer. Med. Recorder, 1823. 

3 London Lancet, July, 1853. 



792 LOCAL DISEASES. 

with the nates elevated 45°. With the common India-rubber — or, better, 
the fountain syringe — and the aid of an assistant the liquid should be gently 
thrown into the rectum until the abdomen is fully distended. By carry- 
ing the fingers, firmly but gently applied upon the abdominal walls, along the 
direction of the colon, the liquid is made to press against the lower end of 
the intussusception. The same gentleness and perseverance are required in 
kneading and pressing the abdominal walls as in the treatment of hernia by 
taxis. If the invagination be in the descending colon, probably only a small 
quantity of the liquid can be injected, and it may be forcibly returned, but 
by repeating the injections a sufficient quantity can ordinarily be introduced 
to obtain the full effect of the mode of treatment. There is also sometimes 
an increased irritability of the rectum, even when the intussusception is at 
the upper extremity of the large intestine, so that tenesmus and expulsive 
efforts follow the introduction of the instrument. The assistant can aid in 
overcoming this and in retaining the water by pressing the soft parts of the 
nates around the instrument. 

If the injection fail to reduce the displacement, it may be repeated after 
allowing the patient to rest for a while. In the New York Medical Journal 
for May, 1875, is the history of an interesting case which was treated 
by Drs. Church and Warren, and is reported by the latter. The infant 
was seven months old and had the usual symptoms, such as frequent parox- 
ysmal pain in the abdomen, vomiting, tenesmus, and scanty muco-sanguineous 
stools. On the third day injections were twice employed without result, but 
on the fourth day an injection of ten or twelve ounces reduced the displace- 
ment and the infant recovered. In a second case treated by Dr. Warren the 
age was nine months, and a tumor appeared a little above the umbilicus a few 
hours after the commencement of the symptoms. The following is Dr. War- 
ren's account of this interesting case, which will give a clear idea of the proper 
mode of treatment : 

" The patient was looking very pale and prostrated, the pulse was quick 
and feeble, and the skin cold. I at once determined to use fluid injections, 
and, with the little patient placed in a semi-prone position in his mother's lap, 
with an ordinary Davidson's syringe I commenced injecting tepid soap-and- 
water, but after perhaps a gill had been thrown into the rectum it was almost 
immediately rejected, very highly colored with blood, and mixed with it a 
very small quantity of mucus and fecal matter ; the latter, by the way. not 
hardened, but of the consistency of soft putty. In a second attempt the 
fluid was retained longer, but was after a little while discharged, with more 
blood and mucus, but with much less tenesmus and pain. 

" When, soon after, I made my third attempt, the child's chest was rested 
upon the side of its mother's lap, with the lower extremities elevated by an 
assistant, so that the position was at an angle of about 45°, anus upward. 
This time I injected the fluid very slowly, in order to avoid, if possible, the 
irritation caused generally by the frequent emptying and refilling of the 
syringe (which, by the way, is a very serious hindrance to the successful use 
of this syringe, and which renders it much inferior to the fountain or hydro- 
static). In this manner I succeeded in injecting, as I estimated at the time, 
perhaps ten or twelve ounces, and during the operation the child gradually 
became more quiet, and had, when I ceased, fallen asleep. Then, with the 
direction that occasional doses of tinct. opii camph. should be administered 
during the night, to control, if possible, the peristaltic action of the intes- 
tines, I left him. 

" On the following morning, to my surprise, I found the child sleeping 
quietly and naturally, and I was informed that at about 5 A. M. (six hours 
after my visit) he had a movement of the bowels, which was saved for my 



INT USS USCEPTION. 793 

inspection, and consisted simply of the enema, slightly colored with fecal 
matter. From that time he seemed to be entirely free from pain, and six or 
seven hours later had a natural passage, after which recovery progressed 
rapidly, and in a few days he was discharged well." 

The following case is interesting as showing success from the use of 
injections after the lapse of two days in a severe case which had resisted 
treatment on the first day. The good result was apparently in great part due 
to the manipulation, which was made so as to press the water against the 
course which intussusceptions are known to take. 

On September 10, 1876, I visited, with Dr. Gillette, a nursing infant aged 
nine months whose history was as follows : It was habitually constipated, but 
it continued in its usual health till September 8th, on which day it was carried 
by its nurse to one of the city parks. After its return it began to be fretful ; 
it vomited and seemed to be in pain. It continued to vomit frequently, espe- 
cially after nursing or taking drinks, and in the ensuing night passed two 
scanty stools of mucus and blood without fecal matter. In the morning of 
September 9th, Dr. G-. was summoned, who found the pulse 180 and tem- 
perature 102°, and the matter vomitedgreenish like bile. In the evening the 
temperature was 102f°. Dr. G. diagnosticated intussusception, and employed 
injections of water, but they were returned without bringing fecal matter and 
without apparent result. He also administered opiates by the mouth. 

September 10th : Temperature 102f° ; features pallid, beginning to have a 
pinched or sunken appearance, and indicative of much suffering ; no nutri- 
ment is apparently retained on account of the frequent vomiting, and the 
bowels are obstinately constipated. As the symptoms indicated rapid sink- 
ing and collapse, consultation was called at 4 p. m. It was impossible to 
determine certainly, through the abdominal walls, on account of the disten- 
tion, whether there was any tumor, but it was my opinion and the opinion of 
one of the other physicians that a tumor, hard and inelastic, could be felt 
nearly in the median line between the umbilicus and the symphysis pubis. 
At about 5 P. M. the shoulders of the little patient were lowered and the 
nates elevated, so that the trunk formed an angle of perhaps 45° with the 
horizontal, and a large quantity of tepid water was gently passed into the 
intestine through Davidson's syringe, with the vaginal nozzle attached. It 
was impossible to estimate the quantity retained, since a considerable part of 
it escaped, although the anus was firmly pressed around the instrument. 

When the abdomen was distended as fully as seemed justifiable, the nates 
being still elevated, and the liquid retained, so far as possible, by firm pres- 
sure upon the anus, the abdomen was firmly and deeply kneaded by the 
hand, the movements being made chiefly from the right lumbar toward the 
right inguinal, and from the right inguinal toward the hypogastric region. 
The kneading was continued perhaps eight or ten minutes, and the water, 
which contained no perceptible amount of fecal matter, blood, or mucus, was 
allowed to escape. 

After this operation the child became quiet, slept, and the vomiting 
ceased. At our next visit, at 7 P. m., although the severe symptoms had 
in a great part abated and the countenance had lost that pinched and suffer- 
ing aspect which was so prominent before, it was deemed best, in consulta- 
tion, to repeat the injection, and this time through a rectal tube, which was 
introduced farther than the nozzle employed at the preceding visit. The 
body was placed in the same position as before and the abdomen kneaded in 
the same manner. The water, when allowed to return, brought no fecal mat- 
ter, but the last that flowed contained two shreds, the largest about one inch 
in length by two lines in width, resembling matted and nucleated epithelial 
cells. It was believed that they were composed of such cells, with perhaps 



794 LOCAL DISEASES. 

some of the mucous membrane to which they were attached, and that they 
were detached from the invaginated portion. An opiate mixture was now 
prescribed, to be given sufficiently often to relieve any restlessness and keep 
the patient quiet, and a flaxseed poultice was applied over the abdomen. 
On the following day the temperature was 103J°, pulse 158, and the abdo- 
men somewhat distended ; but the vomiting had ceased, and there had been 
two fecal evacuations since our last visit. The intussusception had been 
relieved, the inflammatory symptoms soon abated, and the infant's health was 
fully restored. 

Gloodhart reports a case of cure by injecting a boracic-acid solution after 
the symptoms had continued seventy-six hours. The patient's age was eight 
months, and the tumor could be felt per rectum. 1 Humphreys relates two 
cases of recovery by injection of water thirteen and forty hours after the 
commencement of symptoms in infants of eight months and two years. 2 
Butler also succeeded by water injections in reducing intussusception of 
thirty-six hours' continuance in a child of three years. 3 But injections of 
water have not always been successful. Chaffey failed to reduce invagination 
of the caecum and appendix in a " somewhat chronic " case, but inflammatory 
bands were found in their vicinity, 4 and Cripps ruptured the intestine by 
injecting water in a girl of eighteen months. The symptoms had continued 
four or five days and the tumor projected from the anus. 

Injections, in order to be effectual and give promise of success, should be 
aided by gravitation. The physician should remember to elevate the nates 
higher than the shoulders, as in the case related above. Treatment by infla- 
tion — which indeed ought to occur to any intelligent physician appreciating 
the anatomical condition of the parts as deserving of trial — was prominently 
brought to the notice of the profession in modern times by Mr. Samuel 
Mitchell. 5 " I take the liberty," he writes, " of suggesting to the profession, 
through the medium of your valuable periodical, the trial of inflating the 
bowels by means of a glyster-pipe attached to a common pair of bellows ; it 
has fallen to my lot to witness several of these most distressing cases in chil- 
dren ; the nature of the obstruction was foretold during life, and unfortu- 
nately verified by post-mortem examination, The last case of the kind which 
came under my care, about two years since, presented all the usual symp- 
toms — intolerable restlessness, the most obstinate sickness, the singularly dis- 
tressed state of countenance, and shrunken features. The usual remedies 
were had recourse to — viz. warm baths, glysters, anodyne frictions over the 
abdomen, etc. — but without avail. As a forlorn hope I made trial of infla- 
tion by the above means, with the most happy result. The sickness imme- 
diately ceased ; the child within an hour passed a natural stool, and in the 
morning was almost without ailment." 

This mode of treatment is termed novel in the Lancet, but it is really as 
old as the time of Hippocrates, who speaks of throwing air into the bowels, 
by which flatulence is imitated (flatus immitatur). 6 Haller 7 also recom- 
mended the same treatment : " Flatus etiam immissus celerrime susceptionem 
dispellet." Dr. David Greig 8 relates five cases of successful treatment of 
intussusception by inflation. The first, an infant six months old, previously 
in good health, suddenly became very fretful, apparently having severe 
paroxysmal pain in the abdomen. She had vomiting, and finally tenesmus, 

1 London Lancet, Feb. 25, 1888. 2 Ibid., Oct. 27, 1888. 

3 Brooklyn Med. Journ., Feb., 1888. 4 London Lancet, Julv 7, 1888. 

b Ibid., for March 17, 1838. 

6 Hippocrates' Works, translated from the Greek by Grimm, 4 Bd. p. 198. 

7 Physiologia Corporis Humani, torn. vii. p. 95. 

8 Edinburgh Medical Journal, October, 1864. 



INTUSSUSCEPTION. 795 

with bloody evacuations. Warm-water enemata could not be employed, on 
account, the writer thinks, of the spasmodic action of the intestines, and an 
abdominal tumor could be felt near the umbilicus. Castor oil and a purga- 
tive powder and enemata of water having been employed in vain, and the 
case becoming really critical on the second day, inflation was resorted to. 
The writer says : " The nozzle of a small pair of bellows was introduced into 
the anus, and air injected to a considerable extent. Contrary to our expecta- 
tion, the air passed readily into the bowel, and seemed to give the child great 
relief. After the injection it lay very quiet, as if asleep, and evidently quite 
free from pain. In about twenty minutes from the time the air injection was 
administered a slight rumbling noise was heard in the child's abdomen, fol- 
lowed by a crack so loud and distinct as to alarm the attendants in the room, 
who thought something had burst in the child's bowels. The child, however, 
continued as if asleep and free from pain, and in about half an hour a large 
feculent stool, slightly mixed with blood and mucus, was passed without pain. 
During the night the child rested pretty well, had no return of vomiting, took 
the breast as usual, and in two days was quite well." 

Another child, nine months old, treated by Dr. Greig, presenting nearly 
the same symptoms ami the abdominal tumor, also obtained relief by inflation 
after castor oil and enemata had failed to produce any benefit. 

An apparatus for the production and injection of carbonic-acid gas 
has been invented by Schultz & Warker, and is manufactured by them. 
It consists essentially of two glass chambers, one over the other. In 
the lower one a bicarbonate is placed, and in the upper an acid in a liquid 
state. By the gradual admixture of the two carbonic acid is set free. An 
elastic tube conveys the gas from the lower chamber. This apparatus has 
been used by physicians of this city for the reduction of intussusception and 
other purposes, and is a useful invention. 

Syphons of highly- charged carbonic-acid water, from which, when in- 
verted, a powerful current of the gas is evolved, may also be used for the 
purpose of reducing the displacement. Two or three of these bottles, with 
a portion of the tube from Davidson's syringe, which can be readily at- 
tached to the stem from which the gas escapes, constitute all that is required 
for an ordinary case. 

The following cases, which I have treated with Dr. Biichler in 1871, 
show what may be achieved by inflation, and also the unfavorable result 
which must inevitably occur in certain cases. A German infant five 
months old, nursing, began to be fretful, crying often, on March 7th, and 
before night passed a scanty motion of blood. The symptoms continuing, I 
was asked to examine the infant on the 10th, and learned the following facts : 
It had vomited daily, had had daily scanty but infrequent stools, consisting 
chiefly of blood, accompanied at first by tenesmus, but not within the last 
day ; it continued to nurse, but was becoming thinner and weaker, and was 
evidently in pain. The symptoms indicating the nature of the disease, the 
abdomen, which was not distended, was examined for the tumor, which was 
found on the right side in the site of the ascending colon, apparently about 
one and half to two inches in length ; pulse 124 in sleep ; no cough. An 
ineffectual attempt was made to reduce the intussusception by a very rude 
and imperfectly constructed apparatus (the bellows), when from the lateness 
of the hour further treatment was postponed till early the following morning. 
11th. Tumor still detected in the right lumbar region; pulse 120 asleep, 
150 awake. By means of Schultz & Warker's apparatus the intestines were 
inflated so as to produce very decided prominence of the abdomen, and the 
abdomen was gently kneaded. After some minutes the gas was allowed to 
escape, when it was seen that the tumor had disappeared. In a few hours 



796 LOCAL DISEASES. 

a natural evacuation occurred from the bowels, and the infant has remained 
well since. 

The second case ended unfavorably, although the symptoms were appar- 
ently no more grave than in the case just related and had continued a shorter 
time. This infant was also of German parentage. The tumor, firm and 
elongated, could be distinctly felt in the left lumbar region. In this case 
the inverted bottles of carbonic-acid water were employed, and when, after 
considerable delay and kneading of the abdomen, the gas was allowed to 
escape from the intestine, the tumor had disappeared. A few hours after- 
ward convulsions occurred, ending fatally. At the autopsy the invaginated 
mass, which was too firmly strangulated to admit of reduction by inflation, 
was found in the epigastric region, having been carried up from its former 
position by the inflation of the intestine below. It consisted of the terminal 
part of the ileum, which had passed through the ileo-cgecal orifice, and had 
become incarcerated in the ascending colon, and, as is not unusual in these 
cases, the movements of the intestines had changed the location of the tumor 
in the abdomen from the right to the left side. In the London Lancet for 
Feb. 18, 1888, Cheadle reports a case of successful inflation in an infant of 
fifteen months, whose symptoms indicated intussusception of fifteen hours' 
duration, and the tumor could be felt per rectum. Higginson also reduced 
an intussusception by inflation. The patient, an infant of seven months, had 
symptoms of intussusception three days, and the tumor could also be felt 
per rectum. 1 

Whether air or carbonic acid be employed, it is necessary to produce 
distention of the intestine to its fullest extent below the seat of the com- 
plaint without endangering rupture, and of course the sooner it is used the 
better the chance of success. In a few days the displaced intestine has, in a 
large proportion of cases, become so firmly incarcerated, and has descended 
so far, that attempts to replace it, either by injections or inflation, are unsuc- 
cessful ; still, even at a late period, a persevering attempt should be made if it 
have not previously been tried. During the four years which have elapsed 
since the publication of the sixth edition of this treatise in 1886, I have 
treated successfully three — I think I may say four — cases of intussusception 
in infants by frequent rectal injections of warm water as large as could be 
given, and followed by kneading of the abdomen. The youngest of these 

infants was Geo. H. Mc , male, aged four months, nursing, to whom I 

was called on Dec. 24, 1886. He had been very fretful since Dec. 22d, had 
the last fecal evacuation on the morning of Dec. 23d, and had since passed 
stools of mucus and blood without the least fecal matter. Enemata of warm 
water as large as possible were given every hour to two hours with the nates 
raised, and were followed by kneading the abdomen. The fretfulness was 
always less after these enemata. On Dec. 26th the temperature fell from 
101 J ° to normal, and a fecal evacuation, the first in three days, occurred. 
From this time the infant was well. The vomiting, which had been frequent 
since the 22d, ceased on the 26th. The mother stated that the tenesmus, 
which had been a distressing symptom, was uniformly less after the injec- 
tions. My experience during the last ten years with cases of intussusception 
incline me more and more to the belief that copious and frequent warm-water 
injections, employed in the manner described above, are more likely to give 
relief than any other mode of treatment. But it is proper that I should 
state that during this time I have seen cases that were fatal in which this 
and other modes of treatment, including laparotomy, were employed. 

If the modes of treatment which I have recommended above fail to give 
relief when perseveringly and sufficiently employed in a case of acute intus- 
1 London Lancet, May 19, 1888. 



INTUSSUSCEPTION. 797 

susception, the patient's state is one of extreme peril and the prognosis is 
unfavorable. Yet recovery is possible in one of two ways — namely, first, 
by incision through the abdominal walls (laparotomy), and reduction of the 
displacement by the fingers within the abdominal cavity ; and secondly, by 
sloughing of the invaginated mass and union by adhesive inflammation of 
the ends of the intestine which have preserved their vitality. Cripps relates 
a remarkable case of spontaneous cure in an infant of seven months. It had 
been two weeks sick, with vomiting and alvine discharges of blood and mucus, 
when presented for examination. A portion of the large intestine, gangrenous, 
protruded from the rectum. This was cut off, and portions of sloughy sub- 
stance were removed daily for a month afterward, when the child recovered. 
It died of scarlet fever eight months subsequently, and the autopsy revealed 
the entire loss of the large intestine, the small intestine being united to the 
anus. 1 Atrophy of the imprisoned part so seldom occurs in a case which has 
resisted injections and inflation that it need not be considered in this connection 
as a mode of recovery. 

Laparotomy has been successfully performed in a child aged two years, 
as I have stated above, by Dr. Jonathan Hutchinson of London. The case 
was one of those exceptional ones in which great displacement had occurred 
without strangulation. It had continued, as indicated by the symptoms, 
about one month, and a portion of the intestine terminating in the ileo-caecal 
valve had protruded several inches from the anus. " The patient was anaes- 
thetized by chloroform, and the abdomen was opened in the middle line below 
the umbilicus. The intussusception was then easily found and as easily re- 
duced. The after-treatment consisted only in the administration of a few mild 
opiates, and the child made rapid recovery." 2 In a case of this kind there 
can be no doubt of the propriety and necessity of laparotomy as the last 
resort, for, there being no strangulation, sloughing could not occur, and death 
sooner or later from exhaustion must be the result. Cases of this sort have 
usually been left to perish after the ordinary modes of relief have failed. 
Thus as far back as 1784, M. Robin published 3 the case of a child aged 
three and a half years who died after the lapse of three months with a 
caecum protruding from the anus ; and in the American Journal of Medical 
Science for 1849, Dr. Worthington published a similar case, in which a child 
aged three years and four months lived a longer time. In these days of 
anaesthetics, and with the brilliant success of Hutchinson, a physician would, 
in my opinion, be reprehensible if he allowed a child aged two years or over 
with this form of displacement to perish without strongly advising laparotomy 
when injections with water have failed. 

But the question arises whether in those more frequent cases of intussus- 
ception in young children in which, after displacement has continued a few 
hours, there is such firm constriction of the invaginated mass that the patient 
suffers much pain and constitutional disturbance, and passes blood and mucus 
without fecal matter, laparotomy is justifiable. This operation in the case of 
infants has heretofore been regarded as so dangerous and so likely in itself 
to prove fatal that the profession have generally considered it unjustifiable, 
believing that, although death was nearly certain without it, the perform- 
ance of it did not increase the chances of a favorable result. Dr. J. B. Sands 
of New York has recently shown that laparotomy is justifiable as a last resort 
for the relief of this form of intussusception, even in the youngest infants, 
and in the following case, recorded in the New York Medical Journal, June, 
1877, saved the patient, who doubtless would otherwise have perished : 

On March 11, 1877, an infant of six months suddenly presented the cha- 

1 Brit Med. Journ., June 2, 1888. 2 London Lancet, November 22, 1873. 

3 Mem. de V Acad, de Chirurg. 



798 LOCAL DISEASES. 

racteristic symptoms of intussusception, such as tenesmus, abdominal pain, 
vomiting, and bloody stools. A few hours later, when Dr. Sands was called, 
the pulse was rapid and feeble, with symptoms of collapse. An elongated 
tumor could be felt in the abdomen, extending from the left iliac region to 
the left hypochondrium, inelastic, tender on pressure, and dull on percussion. 
The lower end of the invaginated mass could be readily touched by the finger 
introduced into the rectum. The usual methods to effect reduction were at once 
employed with partial success, for the tumor disappeared from the site where 
it had been discovered, and was reduced to a small and firm mass on a level 
with the umbilicus, but it resisted any further attempts to effect its reduction. 

Dr. Sands then, having etherized the patient, made an incision in the 
median line of the abdomen, extending downward about two inches from a 
point a little below the umbilicus. Through this opening, proceeding cau- 
tiously and using as little violence as possible, he was able, after some delay, 
to reduce the displacement. The invaginated mass, which was only one and 
a half inches in length, consisted of the terminal portion of the ileum and 
caecum, which had entered the ascending colon. The wound was closed by 
five silver sutures, which embraced the peritoneum, and the patient made a 
good recovery. The operation was performed eighteen hours after the com- 
mencement of symptoms. 

Dr. Sands has collected the statistics of 20 cases of laparotomy for intus- 
susception occurring at different ages in which the result was stated. Of 
these, 7 recovered, or 1 in 3 ; but he judiciously remarks, considering the 
gravity of the operation, that it is doubtful whether future statistics will 
show so favorable a result of laparotomy for this displacement as to justify 
the frequent use of the knife. For facts and statistics relating to this sub- 
ject the reader is referred to an able and elaborate paper by Dr. Ashhurst. 1 

It is obvious that the earlier the displacement is recognized, the greater 
the probability of the reduction by the judicious use of injections or infla- 
tion, and it is seen from cases related above that this treatment may be suc- 
cessful as late as the second or third day, after previous attempts to reduce 
the intussusception by the same means have failed, and when there is that 
degree of strangulation that bloody stools occur. But, as my own experi- 
ence has shown me, there is also inevitably a large proportion of cases in 
which the use of injections and inflation, however judiciously and perse ver- 
ingly made, totally fails, and it seems to me, in the light of present expe- 
rience, that when pressure from below by water, air, or gas, which is the only 
efficient mode of treatment short of the knife, has been tried sufficiently long 
and sufficiently often without result, it is the duty of the physician to seek sur- 
gical advice in reference to laparotomy, as he would in a case of hernia, espe- 
cially since, under Lister's antiseptic method, the danger from severe operations 
appears to be considerably diminished. It may be added that laparotomy 
performed on the first or second day will be much more likely to save life in 
ordinary cases than if performed later, since the strangulated intestine is 
soon badly damaged, and a local peritonitis is likely to be developed any 
time after the first forty-eight hours. 

When an intussusception has reached that stage in which active inter- 
ference by injections, inflation, or laparotomy is no longer proper, the physician 
can only prescribe opiates with sustaining measures and an emollient poultice 
over the abdomen, and must await the result. The diet should consist of 
beef juice and other concentrated nutriment which leaves little residuum. 
Vomiting, which is so common, is best controlled by bismuth and opiates ; 
convulsions require the bromide of potassium and an enema of three to five 
grains of chloral hydrate dissolved in a little water. 

1 American Journal of the Medical Sciences, for July, 1874. 



APPEXDICITIS. 799 

CHAPTER XIII. 

APPENDICITIS AND PEKITONITIS. 

Appendicitis. 

Etiology. — The most common cause of this inflammation is the lodge- 
ment and impaction in the appendix of fecal matter or hard, indigestible 
foreign bodies which produce inflammation, and sometimes perforation, by 
their pressure. In 146 cases of perforation of the appendix collated by Mat- 
terstock, fecal concretions were present in 63 ; foreign bodies different from 
concretions in 9 ; neither fecal masses nor hard bodies in 8 ; and in the 
remaining cases the records do not mention the presence of any substance 
likely to cause inflammation. In 49 cases of fatal appendicitis in children, 
perforations had occurred in 37. The analysis of 152 cases collated by Fitz 
gives a very similar result to that obtained from the examination of Matter- 
stock's records ; but Hagen ascertained the presence of fecal concretions in 
69i per cent., and hard bodies not concretions in 30t> per cent., of the cases 
of perforation of the appendix. We must therefore regard foreign sub- 
stances, either concretions or other hard bodies which act mechanically by 
pressure, as the common cause of appendicitis, perforation of the appendix, 
and consecutive inflammations extending from the appendix. 

The fecal concretions found in the appendix are single or multiple, and 
of different degrees of hardness. The hardest masses sometimes exhibit con- 
centric layers and contain phosphate of calcium. Exceptionally, the concre- 
tion has a nucleus of some solid substance in the interior. The foreign bodies 
which lodge in the appendix and cause ulceration are numerous. In a case 
in my practice an over-baked bean, hard and black, perforated the appendix 
and caused an abscess, which by rupturing produced fatal peritonitis. Among 
the substances which have caused perforation and been recovered we may 
mention hard fecal matter, small buttons, beads, grape-seeds, cherry-stones, 
orange-seeds, raisin-seeds, apple-seeds, and seeds of other fruits. 

A perforation occurring in this manner allows fecal, purulent, or gan- 
grenous matter to escape into the abdominal cavity, causing peritonitis. A 
perforation occurring in this way is indeed the most common cause of 
peritonitis in children. 

Anatomical Characters. — The initial lesions take place in most 
instances in the appendix. Ulceration or necrosis of its epithelium occurs 
from pressure of the foreign substance ; then the intestinal microbes invade 
the exposed subepithelial tissue, causing septic inflammation. This inflam- 
mation extends through the muscular coat to the subperitoneal connective 
tissue and peritoneum, causing peritonitis. 

The extension of the disease and adhesive peritonitis around the ulcerated 
appendix is common. The extent and gravity of the peritonitis depend on 
the size of the perforation and the quantity of pus or feculent matter that 
escapes. If the substance which escapes from the perforation be considerable 
and highly irritating, the inflammation is of course severe and suppuration 
results. Its location depends upon the place of perforation. It is stated that 
in most instances the centre of the abscess is behind or alongside the caecum, 
and if it extend upward its walls consist of intestine and the posterior and 
lateral parietes of the abdomen. If the appendix be long and extend to the 
brim of the pelvis minor, and the perforation be near its distal end, a some- 
what rare occurrence, the abscess may press upon the rectum or uterus. 



800 LOCAL DISEASES. 

The abscess, left to itself, may open in any direction. It sometimes dis- 
charges into the intestine, either into the lower end of the ileum, the c^cum, 
ascending colon, or rectum, through an opening that is quite small in the 
mucous membrane, but larger in the other intestinal coats. Evacuation of 
the pus per rectum, sometimes tinged with blood, has been regarded as favor- 
able from the time of Dupuytren. It occurred in 18 per cent, of the cases 
collated by Fitz, the pus breaking into the intestine at some point above, and 
escaping by the rectum. But the result is not always favorable when the 
abscess breaks into the intestine, for after the pus has been evacuated fecal 
matter may escape from the intestine through the opening, carrying with it 
microbes which may poison the system and set up septic fever. Of 6 cases 
related by Demme in which the abscess broke into the intestine, 3 subse- 
quently died. In a case treated by the late Dr. F. M. Warner and myself a 
boy of about eight years recovered in this manner. Henoch states that 
abdominal abscesses are very prone to escape at the umbilicus, since this is 
the weakest part of the abdominal wall. Rarely the pus makes a passage 
into the bladder, and if this occur cystitis, due to the presence of purulent 
and fecal matter, may result. The inflammation has also, in a case mentioned 
by Eisenchiitz, extended from the perforated appendix to the right ovary, 
producing purulent inflammation in this organ. Extension of the inflamma- 
tion from the perforated appendix to and around the contiguous blood-vessels 
may produce disastrous results. The superior mesenteric vein, which con- 
veys blood from the caecum and appendix to the portal vein, sometimes 
becomes the seat of thrombosis, the circulation in its branches being inter- 
rupted by the presence and pressure of inflammatory products. Detached 
particles of the thrombi, conveyed through the portal vein to the liver, pro- 
duce septic inflammation and abscesses in this organ. Matterstock has the 
records of eleven cases in which the liver became involved in this manner. 
Occasionally the abscess ascends along the colon and behind the liver, becom- 
ing subdiaphragmatic, and cases have been reported in which it entered the 
right pleural cavity. Tillmann states that in 22 cases of fecal fistula extend- 
ing into the pleural cavity 6 originated from perforations in the appendix. 
The abscess penetrating the retro-peritoneal tissue may extend to the kidney, 
so as to become perinephritic, or it may descend along the psoas and iliac 
muscles, even under or below Poupart's ligament. Cases are reported in 
which it burrowed under the gluteus maximus muscle or in the perirectal 
tissue, occupying the sacral or coccygeal region. 

Evidently, inasmuch as the appendix is invested by peritoneum, its per- 
foration and the escape of fecal substance or a foreign body, which produces 
the abscess described above, cannot occur without a localized peritonitis behind 
and below the caecum, where the appendix lies. But a more serious and 
ordinarily fatal result sometimes follows — to wit, the occurrence of acute dif- 
fuse peritonitis. This may take place immediately after the perforation, but 
frequently an abscess forms, perhaps of little extent, around the appendix, and 
it may continue for weeks or months without producing any dangerous symp- 
toms. Finally it bursts, and its contents escape into the general peritoneal 
cavity, producing an acute peritonitis, which rapidly extends over the perito- 
neal surface. A large proportion of the cases of perforation of the appendix 
if left to themselves terminate, after a time, in this manner, in peritonitis, 
which from its extent and severity is usually fatal. This was the result, ac- 
cording to Volz, in 31 of 39 cases, and, according to Cless, in 7 out of 8 cases. 

Symptoms. — The initial symptom of this form of inflammation is pain, 
more or less severe, in the region of the appendix, perhaps at first paroxysmal, 
with intervals of comparative ease, but accompanied by tenderness. The 
patient is apt to have nausea and even vomiting, constipation or diarrhoea, 



APPENDICITIS. 801 

flatulence, and tenesmus, so that experienced physicians sometimes err in 
diagnosticating a milder disease, not aware of the serious malady which is 
impending. These symptoms in the initial period frequently abate for a day 
or two, and the patient is able to be about, but they return with equal or 
greater severity. 

When the disease continues, the pain in the caecal region is so constant 
that the patient takes to bed, unable to stand upright or to walk. He inclines 
forward and to the right, and his right thigh is flexed to relieve the tension. 
Sometimes he refers the pain to the epigastrium or the abdomen, and it is 
increased by coughing, by full inspiration, and by extension of the right 
thigh when the peritonitis begins. Vomiting of the- ingesta mixed with 
mucus and bile is common, and eructations of gas may occur. Occasionally 
these symptoms are preceded by a chill, but less frequently in children than 
in adults. The following are the symptoms commonly present : anorexia, 
thirst, fever with morning remissions (101° to 103° F.), accelerated pulse, 
features indicative of severe sickness, sometimes icteric hue of skin and con- 
junctiva, perhaps dysuria, scanty urination or retention of urine, diarrhoea 
or constipation ; abdomen flat and muscles tense at first, but subsequently 
abdomen tympanitic ; tenderness on pressure at first in the right iliac region, 
but subsequently more general; prominence of the ileo-caecal region, at first 
from gas, subsequently from exudates ; a caecal tumor, tender and immovable ; 
adjacent loops of intestine distended. Such are the symptoms and phenomena 
that attend this disease. Pressure of the crural plexus may cause numb- 
ness, pain, or other abnormal sensation in the right leg and the external 
genital organs. Pressure on the iliac vein may retard the return circulation 
from the leg and cause oedema of the limb. 

The progress of this disease and its gravity vary greatly in different cases. 
In the mildest forms of the inflammation, the pain, nausea, fever, ileo-caecal 
tenderness, and fulness gradually abate, and in two or three weeks the health 
is restored : or the symptoms may continue longer, but finally yield after the 
discharge per rectum of gas and offensive feces. A deep-seated induration and 
soreness, gradually abating, may remain at the seat of the disease for months, 
and the patient may complain of aching or pain after a full meal or active 
exercise. When the abscess opens into the intestine the dangerous symp- 
toms abate rapidly, and the patient, as a rule, quickly begins to convalesce. 

In other cases the symptoms continue, but with some remission due to 
the fact that the abscess, which does not discharge, becomes surrounded by 
condensed connective tissues which limit its extension. Then, perhaps after 
some unusual effort or a blow or pressure upon the inflamed part, an aggra- 
vation of symptoms occurs. Purulent or septic matter has probably escaped 
at some point, and peritonitis may have resulted, or burrowing of pus, as has 
been described above, or septic inflammation in some important organ. The 
sudden advent of alarming symptoms when the patient has been compara- 
tively comfortable, severe and general abdominal pain,' prostration, rapid 
pulse (150 to 160), a high temperature (105° or 106°), or abnormally low 
for the other symptoms, painful respiration, tenseness of the abdominal mus- 
cles, followed by tympanites and distention, indicate rupture of the abscess, 
general peritonitis, and rapidly approaching death, unless early and imme- 
diate laparotomy be performed and the peritoneal cavity be irrigated by a 
warm antiseptic lotion. In this alarming state vomiting, gaseous eructa- 
tions, constipation, more rarely diarrhoea, retention of urine, clammy perspi- 
rations, hiccough, flexed thighs, pallor, and finally collapse, indicate the fatal 
progress of the disease. 

To add to the gravity of the situation, septic inflammations in other parts 
sometimes start up, as empyema or pericarditis, cystitis, perhaps with per- 

51 



802 LOCAL DISEASES. 

foration of the bladder, inflammation around or within the female genital 
organs or in the retro-peritoneal connective tissue. 

On the other hand, it must be remembered that in a considerable propor- 
tion of cases the abscess is so encapsulated that septic poisoning and diffuse 
peritonitis are prevented, at least for a time. 

Of the symptoms enumerated above, pain is one of the most constant, 
and was present in 84 per cent, of the cases collated by Fitz. It is of course 
less severe if the inflammation is localized in the ileo-caecal region and of 
little extent than when it occupies a wider area from the extension of peri- 
tonitis. 

Vomiting is one of the most common symptoms. It was absent in only 
2 of the 72 cases collated by Matterstock, and was present in Pepper's 13 
cases. It appears to be more common in children than in adults. Diarrhoea 
was present in 33.3 per cent, of Matterstock's cases, and constipation in 46.6 
per cent., alternating constipation and diarrhoea in 15.5 per cent., and normal 
stools in 4.5 per cent, of the cases. According to Pott, diarrhoea is more 
common than constipation in children, 1 and in fatal cases approaching termi- 
nation severe colliquative diarrhoea sometimes occurs. 

More or less fulness and induration can usually be detected in the ileo- 
caecal region at an early as well as late stage of the disease, but a distinct 
tumor is only occasionally perceptible. According to Pepper, in 19 children 
with this disease a tumor could be detected in only 3 instances. A dull per- 
cussion sound in the right ileo-caecal region is common, but occasionally, 
even when there is considerable inflammatory induration, loops of intestine 
distended with gas lie over the seat of inflammation, so that the percussion 
sound is resonant. The temperature usually ranges from 100° to 103° or 
104°. It is sometimes remittent, In a case treated by the late Dr. H. B. 
Sands the temperature fell from 101.6° before laparotomy to 98.5° imme- 
diately after the operation, and it remained below 100° during convalescence. 
A sudden rise in temperature indicates extension of inflammation or perhaps 
the occurrence of septic inflammation in organs not previously involved. A 
sudden fall of temperature when other symptoms are grave, like cessation 
of pain, indicates collapse. 

Diagnosis. — Recurring pain or tenderness in the caecal region at intervals 
of a few weeks should excite suspicion of the presence of a foreign sub- 
stance in the appendix. Dr. C. E. With 2 found that such recurring attacks 
preceded the severe disease for weeks, months, or even years in certain cases, 
and in the large number of cases which he collated, Matterstock ascertained 
that these occasional attacks of pain and tenderness preceded the disease in 
8 per cent, of the children affected. Sometimes the accumulation of fecal 
matter in the caecum can be determined by palpation, since it produces a 
" doughy " feel. The diagnosis of this inflammation from invagination is not 
difficult, since the latter occurs chiefly in infancy, is attended by a tumor 
more centrally located in the abdomen than the ileo-caecal induration which 
we are considering, and is attended often by bloody stools and fecal vomiting. 
Dr. V. P. Gibney 3 states that four children with perityphlitis had been 
brought to his orthopaedic hospital in the belief that they had hip disease, 
and had been treated for it ; but a more careful examination of such cases, 
especially under ether, shows that the hip-joint is not affected. The swelling 
in hip-joint disease is lower down than the perityphlitic induration. Besides, 
perityphlitis does not produce the change in the appearance of the hip when 
examined from behind, or in the position of the foot, which we observe in 

1 Jakrbuch fiir Kinderheilk., N. F. xiv. 

2 Peritonitis Appendicularis, etc., Kjobenhavn, 1879. 
3 Ainer. Journ. of Med. Sci., 1881. 



APPENDICITIS. 803 

hip disease. N. Senn l recommends rectal injection of hydrogen gas as a 
means of determining the presence of perforation of the caecum or appendix, 
since in case of perforation the gas enters the peritoneal cavity, and lapa- 
rotomy without delay is indicated. The diagnosis from a psoas abscess may 
be made by attention to the following facts : This abscess occurs gradually, 
without symptoms referable to the intestines or peritoneum, and without the 
ileo-caecal induration of perityphlitis. Moreover, the abscess usually descends 
along the psoas muscle and forms a swelling under Poupart's ligament, or it 
extends along the thigh under the fascia. 

Prognosis. — This varies greatly in different cases. If the inflammation 
be of little extent and encapsulated, and sepsis do not occur, the prognosis is 
good. On the other hand, if the perforation of the caecum or appendix be 
of considerable size, with considerable escape of feculent matter, loaded as it 
is with microbes, the severe inflammation which results in the peritoneum or 
retro-peritoneal tissue, with perhaps consecutive septic inflammation in adja- 
cent organs or tissues, to which septic matter has been conveyed by the 
lymphatics or blood-vessels, a fatal termination is almost certain. It is evi- 
dent that the statistics relating to the result, as ascertained by different 
writers, vary according to the average severity of the cases whose records 
they consult. The following statistics have been published, showing the 
mode of termination of appendicitis, extending in many of the cases which 
ended fatally so as to cause more or less typhlitis, perityphlitis, and perito- 
nitis : 

Authors. Deaths. Recoveries. 

Volz 39 10 

Bamberger 18 ........ 55 

W. T. Bull 33 34 

Matterstock 49 21 

With 12 18 

Demme 27 9 

According to Matterstock, age influences the result in a measure, since 
of 12 patients under the age of six years, 11 died ; of 24 patients between 
the ages of six and ten years, 15 died ; and of 34 patients between the ages 
of ten and fifteen years, 23 died. A diffuse peritonitis, whether resulting 
immediately from the perforation or from rupture of an abscess which has 
been previously encapsulated and indolent, is usually fatal. Evacuation of 
the abscess into the caecum or rectum justifies a favorable prognosis, though 
some die in which this occurs. Evacuation of pus through the abdominal 
walls, if it takes place at an early date, is also regarded as favorable. Lapa- 
rotomy, as this operation is designated, if performed at the proper time and 
with antiseptic precautions, greatly increases the chances of recovery. 
According to Noyes. 2 in 100 such operations the mortality was only 15. But 
according to Bull, the result is not so favorable if the abscesses burrow their 
way to the surface and open without surgical assistance, for of 28 such 
abscesses, 11 were fatal. 

How long patients may live in fatal cases after the occurrence of severe 
symptoms has been investigated by Fitz, who found that in 176 cases 34 per 
cent, died in the first five days, more than half in the first week, 31 per cent, 
in the second week, and 4 per cent, in the third week. In those mild cases 
in which the inflammation in the caecal region is of slight extent and the 
patient is soon convalescent, a sudden aggravation of symptoms sometimes 
occurs from breaking loose of the inflammatory products of septic absorp- 
tion, and the case ends fatally. 

1 Journ. of the Amer. Med. Assoc, June 23, 1888. 

2 Trans. Rhode Island Med. Soc., 1882. 



804 LOCAL DISEASES. 

Treatment. — Prophylactic. — Children should have plain and easily- 
digested diet, from which seeds or other indigestible substances are removed 
as much as possible. They should be instructed to reject the seeds of the 
ordinary fruits which they are allowed to eat, since seeds are the offending 
substances which cause appendicitis and perforation in so large a proportion 
of cases. Daily fecal evacuations should be procured, so as to prevent fecal 
accumulation in the caecum. If there be complaint of colicky pain in the 
abdomen while the bowels move regularly, or if there be occasional pain or 
aching in the caecal region, a careful examination should be made in order to 
ascertain if there be tenderness or induration at the point complained of, and 
if so, a quiet life with open bowels should be enjoined. By such measures 
the threatening symptoms may pass off. 

Curative. — The late Prof. Henoch of the University of Berlin, whose 
opinions relating to the diseases of children always claim attention, if not 
acceptance, on account of his large experience, says that whether the inflam- 
mation occurs from over-distention of the caecum by fecal masses or from 
concretions in the appendix, the symptoms are the same as in later life — to 
wit, pain in the caecal region, which is likely to extend over " a large part of 
the peritoneum ; the frequent formation of a tumor by the exudation, which 
not infrequently terminates in suppuration ; the repeated relapses, etc." 
Henoch states that he keeps the intestines perfectly quiet by opium, and only 
gives castor oil or calomel when prolonged constipation and palpation indicate 
the presence of a large fecal accumulation in the caecum ; otherwise, he ab- 
stains from purgatives, applies a few leeches, without after-bleeding if there 
be much tenderness, gives an emulsion of oil (emulsio oleosa), with the 
aqueous extract of opium every two hours, and uses constantly the ice-bag 
over the caecum. When with this treatment the pain and tenderness cease, 
he states that defecation usually occurs spontaneously or is produced by a 
simple enema or a dose of oil. The following remark might be thought to 
be an exaggeration were it not for the well-known accuracy and high profes- 
sional standing of Prof. Henoch : " When this treatment was begun early 
enough, recovery ensued in almost all cases, and if a swelling had been formed 
by the exudation, its transition into suppuration was prevented even in chil- 
dren who in the course of a few years had been repeatedly admitted to the 
hospital on account of relapses." The treatment detailed above, employed 
and recommended by Prof. Henoch, is in my opinion the best that can be 
prescribed for typhlitis, appendicitis, and perityphlitis before suppuration has 
occurred. The use of laxatives, unless sometimes laxative enemata, should 
be postponed until the tenderness and other inflammatory symptoms have to 
a considerable extent abated by the use of a warm flaxseed poultice, or, if the 
temperature be above 103°, the ice-bag, and opium in sufficient doses to allay 
restlessness and procure sleep should be employed. If, when the inflammation 
has been subdued, we ascertain by palpation the presence of fecal masses in 
the caecum, a large clyster of warm water, containing one ounce of glycerin 
and one of sweet oil, may be prescribed, or perhaps, as recommended by 
Henoch, a dose per orem of castor oil or calomel may be given. Even in 
the commencement of the treatment, if there be the history of constipation, 
and on palpation the caecum appears to be distended with fecal matter, it is 
proper to employ a large clyster of warm water, containing one ounce of 
glycerin and one of sweet oil, in order to remove a chief cause of irrita- 
tion. The diet should consist of liquids that leave little residuum, as the 
beef peptones and peptonized milk. Carbonized water may be allowed to 
relieve the thirst or nausea. If the case result favorably, the child should 
lead a quiet life, avoiding violent exercise during and after convalescence, 
for relapse is not infrequent. 



PEEITOXITIS. 805 

But in appendicitis, with the contiguous inflammations, typhlitis and peri- 
typhlitis, or without them when the inflammation persists, an abscess results ; 
and in recent years many lives have been saved by the incision and drainage 
of the abscess. 

In America the advantages of early liberation of the pus in ileo-cascal 
abscesses was brought to the notice of the profession by the late Prof. Wil- 
lard Parker, whose first case of successful operation occurred in 1843. Since 
this time the treatment of perityphilitic abscesses by incision has been prac- 
tised in numerous instances, so that Dr. B. F. Noyes was able to collate the 
records of 119 cases, only about 16 per cent, of which were fatal. 1 

Dr. Sands strongly objected to the use of the exploring needle at an early 
stage of the inflammation, employed for the purpose of determining the 
presence or absence of pus, since it might penetrate the healthy peritoneal 
cavity and pierce the intestine or pus-cavity, and when withdrawn the foul 
substance adherent to it would probably infect the peritoneum and cause a 
diffuse peritonitis. G. Buck, Wier, and Bull advise, if the presence of pus 
be determined by the needle, to leave it in situ, that it may serve as a guide 
in making the incision. Morton states that the aspirator needle should never 
be used, and Bansohoff also objects to it. Dr. Lange 2 in making the incision 
and entering the peritoneal cavity, finding that the tumor was covered by 
omentum, closed the opening and made the cut farther to the right, where 
the peritoneum was adherent to the tumor, and the patient recovered. 

Sands recommends making a vertical incision over the tumor, as affording 
the readiest approach to the diseased parts. Noyes, Parker, Hancock, and 
others make the incision, four inches in length and even longer, in a line 
parallel with the outer half of Poupart's ligament. Hadden and Bontecou 
make a curved incision along the crest of the ileum, and others, as Gibney 
and Parker, make the incision at the most prominent part of the tumor and 
nearer the median line than most other operators. 

Laparotomy, or the opening of the abdominal cavity for the purpose of 
evacuating the abscess, has been performed a considerable number of times 
during the last ten years, and cases have been published showing very favor- 
able results. 

Peritonitis. 

The peritoneum is very extensive. It is a serous membrane and a closed 
sac, except in the female at the extremities of the Fallopian tubes. It covers 
all the viscera in the abdominal and pelvic cavities, and is reflected over their 
parietal surfaces, forming by its extension the greater and lesser omentum. 
Its free surface is moist, smooth, and covered by a layer of thin squamous 
epithelium, while its under surface connects with the underlying viscera, and 
fascia, in which the muscles, blood-vessels, lymphatics, and nerves lie. The 
great extent of the peritoneum and the large number of lymphatics in it 
render its inflammation dangerous, and, if it be general, likely to be fatal. 

Etiology. — The earliest form of peritonitis occurs in the foetus, rendering 
it non-viable. This form ordinarily originates from syphilis. Septicaemia is 
also a common cause of peritonitis in the newly-born in filthy and degraded 
families. If sanitary precautions are neglected and the habits of the house- 
hold are filthy and degraded, germs from sources of uncleanliness are liable 
to enter the umbilical fossa. We have shown elsewhere how pathogenic germs 
derived from the decaying cord not infrequently enter the umbilical vessels 
and lymphatics, and are conveyed to different and distant parts, setting up 
inflammation in the peritoneum as well as elsewhere. 

Prudden and Delafield state that peritonitis may occur without apparent 

1 Trans, of Rhode Island Med. Soc, 1882. 2 N. Y. Med. Journ., Mar. 3, 1888. 



806 LOCAL DISEASES. 

cause, but it is more frequently produced by appreciable agencies. We have 
mentioned syphilis and septicaemia as causes, but the distinguished pathol- 
ogists named above enumerate, among the causes, abdominal wounds, con- 
tusions, ulcers, new growths, intussusceptions, ruptures, perforations, inflam- 
mations of the stomach and intestines and of the vermiform appendix. If the 
inflammation of any organ or tissue covered by peritoneum reach the peri- 
toneum, peritonitis occurs by extension of the inflammation, or by rupture 
of the peritoneum and the escape of irritating matter into the peritoneal 
cavity, which produces a general and usually fatal peritonitis. 

If we exclude peritonitis due to tubercles and that from septicaemia and 
syphilis, it may, in my opinion, be truthfully said that a majority of the cases 
of peritonitis in the young originate from appendicitis. From an anatomical 
point of view we recognize two forms of acute peritonitis, designated the 
cellular and exudative. As described by Prudden and Delafield, the former 
is produced by an irritant of moderate activity. 

After death in this form of peritonitis the entire peritoneal surface is of a 
bright-red color, but with no visible fibrinous, serous, or purulent exudate. 
The endothelial cells have increased in number and size, so as to project 
outward more than in health. The second form of peritonitis, designated 
exudative, was studied experimentally by Prudden and Delafield. In one 
to two hours after the injection of an active irritant into the peritoneal 
cavity of the dog they found a little serum in the cavity, congestion of 
the peritoneum, and points of exuded serum upon the inflamed surface. 
No marked changes occurred in the connective tissue or endothelial cells, 
but pus-cells collected in the stroma under the endothelium, and white blood- 
cells increased in the vessels. Twenty-four hours later the peritoneal con- 
gestion was greater, as well as an increase of serum, fibrin, and pus, and an 
increase and swelling of the endothelial cells. In the human being, if death 
occurs by the third day, which is the common result in experiments on dogs, 
the same anatomical results are observed — to wit, general congestion in the 
peritoneal surface, along with an increase in pus, fibrin, serum, in the number 
and size of the epithelial cells. Death commonly results between the sixth 
and fourteenth days, and the anatomical changes which have occurred vary 
in different cases. Congestion of blood-vessels may be very intense, with 
extravasation of blood, or the latter may be absent. Pus and fibrin in a 
thick or thin layer may cover the adjacent surfaces, or pus may infiltrate 
the entire thickness of the peritoneum and subjacent connective tissue. 

Sometimes the pus is sacculated by adhesions, so as to appear like an 
abscess ; it may have a dirty color from the presence of bacteria ; and it is 
thick or thin according to the relative proportion of serum and pus-cells. 

Acute peritonitis, if it be not fatal or the symptoms are not aggravated 
by the close of the second week, may become chronic. Local peritonitis 
often results from an underlying inflammation commencing in one of the 
viscera and extending to the peritoneal covering. The inflammation may 
be circumscribed by adhesions or may extend so as to be fatal. The most 
important and interesting instances of this kind have only in recent years 
been correctly understood. It is now known beyond doubt, from surgical 
experience and observations in the dead-house, that the peritonitis occurring 
in children previously supposed to be healthy, and ending ordinarily in death, 
results in a large proportion of cases from appendicitis. The lodgement of a 
foreign substance, often fetid and highly irritating, in the appendix causes 
inflammation, ulceration, and not infrequently perforation, with the escape 
of the putrefying matter, which causes a general peritonitis. 

The subject of appendicitis as a cause of peritonitis will be considered 
hereafter. 



PERITONITIS. 807 

Delafield and Prudden describe the following varieties of chronic perito- 
nitis : 

1. Cellular peritonitis ; 

2. Peritonitis with adhesions ; 

3. Chronic peritonitis with thickening of the peritoneum ; 

4. Chronic peritonitis with the production of fibrin, serum, and pus ; 

5. Hemorrhagic peritonitis ; 

6. Tubercular peritonitis : 
(«) Tubercular ascites ; 

(6) Tubercular peritonitis with the production of a large amount of 

fibrin ; 
(c) Tubercular peritonitis with adhesions. 

Symptoms. — Obviously, since peritonitis in many instances results from 
some anterior disease, the symptoms of this disease precede it. Frequently, 
especially during childhood, abdominal pains, often intermittent and vague, 
precede the severe symptoms indicating peritonitis. An appendicitis has 
probably pre-existed. Sometimes an empyema has occurred, more or less 
filling the affected side of the chest with pus, and pus-cells traversing the 
lymph-spaces of the diaphragm appear on its under surface and excite a 
peritonitis, which, commencing in the upper part of the abdominal cavity, 
extends downward. A suppurating mesenteric gland, an ulcerating Peyerian 
patch, scarlatinous uraemia, and a local inflammation, whatever the cause, 
extending to the peritoneum, inevitably give rise to inflammation of this 
membrane. 

Typical peritonitis begins with severe pain, vomiting, and tenderness, in- 
creased by pressure, followed by distention with gas. Sometimes there is 
initial chilliness, followed by a quick pulse and heat of surface ; constipation 
is common ; the countenance is anxious and expressive of suffering ; and the 
legs are flexed. As the disease continues the intestines become distended by 
gas, which increases the pain, and the food is ejected. The loss of appetite 
and loss of food by vomiting, by which, after a time, even bile is ejected, 
cause progressive emaciation and weakness. Hiccoughs, sometimes present, 
greatly aggravate the pain. The eyes become sunken. While the abdomen 
is distended, other portions of the system emaciate. 

The pulse in the beginning of peritonitis is usually accelerated, being 
perhaps from 110 to 150, and the temperature from 101° to 104° F., though 
these symptoms are variable. The pain is usually severe or griping, and is 
increased by pressure or motion, as by a deep breath or a cough. The pain 
is also increased by peristaltic or vermicular movements of the intestines. 
Exceptionally, the pain may be slight. It is usually most severe in perfora- 
tive or traumatic cases before adhesions have occurred. As peritonitis is 
usually local at first, the pain is at first localized, and it extends and becomes 
more severe as the inflammation increases until it is general. Nausea is 
likely to occur when there is no vomiting, accompanied with belching. The 
distention may become such that the abdomen is not only markedly dis- 
tended, so that the skin is smooth and shining, but the diaphragm is carried 
up — the apex of the heart upward and backward ; the liver is carried 
upward and turned on its axis in extreme cases. In severe peritonitis, espe- 
cially from perforation, collapse may soon follow. The pulse is rapid and 
weak, the voice feeble. In severe cases, approaching a fatal termination, the 
temperature may be very high — as high as 108° or even 110° F. It is often 
higher in the latter part of the day than at other times. On the other hand, 
it may be subnormal. The tongue at first is moist, but afterward it becomes 
dry and furred ; in cases of septicaemia or other grave constitutional diseases 
it may be dry and covered by a brown fur from the first. 



808 LOCAL DISEASES. 

The appetite and digestion are greatly impaired, and the food is regurgi- 
tated to a greater or less degree ; constipation is also common, due to paraly- 
sis of the muscular coat of the intestines and fibrinous adhesions. Urination 
may be frequent or of natural frequency, but it is likely to be painful and 
scanty when the inflammation extends to the bladder. At a later stage the 
catheter is often required if, as is usual, the inflammation has extended over 
the bladder and the patient is fully under the influence of opium. In certain 
grave forms of peritonitis a trace of albumen appears in the urine. 

Diagnosis. — It is very important that the diagnosis be made early, for 
correct treatment and the life of the child depend on it. On palpation in the 
beginning of peritonitis the abdominal walls are commonly tense and resist- 
ing. Occasionally the friction between the inflamed surfaces can be detected, 
and the fluctuation is noticed if there be considerable increase of serous exu- 
dation. A clear history of the case, a careful examination of the abdomen 
by palpation, percussion, and change of position, with proper appreciation of 
the history and symptoms, generally will lead to a correct diagnosis. 

If there be general peritonitis, there is general tenderness, fulness, and 
hardness. If the inflammation be limited to one part, that part exhibits 
hardness, fulness, and tenderness, or tympanitic resonance may occur, due to 
distended intestine underneath. The acuteness, pain, vomiting, tympanism, 
fever, and the continuance of these symptoms, with the aspect of severe 
sickness, justify or render probable the diagnosis of peritonitis. If by de- 
cided measures to relieve the patient, which will be mentioned hereafter, he 
do not on the following day express considerable relief from the suffering, 
the case is probably one of peritonitis. 

No physician summoned to a case of abdominal tenderness or pain should 
neglect to examine the region of the appendix vermiformis, located in most 
cases midway between the umbilicus and the anterior superior angle of the 
ileum. From the fact that peritonitis, occurring in those who have previously 
been free from ailment and robust, ordinarily begins in the appendix, this 
region should in such instances be carefully examined by deep pressure with 
the tips of the fingers. The space between the right iliac bone and the um- 
bilicus should be thoroughly explored in order to ascertain if there is any 
tenderness, fulness, or hardness in the site of the appendix. The examina- 
tion can be facilitated by pressing at the same time posteriorly with the 
thumb of the same hand or the fingers of the other hand applied against the 
right lumbar region. By this manner the site of the appendix is grasped 
anteriorly and posteriorly. Prominent surgeons of Xew York with whom I 
have examined cases have sometimes been able by rectal examination with 
the finger to refer the localized peritonitis to an abscess in the appendix. 

Prognosis. — In acute general peritonitis a fatal result should be predicted 
if the diagnosis is clear. I have not yet seen a patient recover who had 
general peritonitis, manifested by intense redness of the entire visceral and 
parietal surfaces, with purulent and commencing fibrinous exudation, as 
shown by a subsequent autopsy. Of course septic or tubercular peritonitis 
is fatal from the primary disease. There can be no doubt that many more 
children with local peritonitis are now cured than formerly, and this improve- 
ment in the result of treatment has occurred chiefly from the surgical meas- 
ures employed in the treatment of the peritonitis caused by and extending 
from an appendicitis. This is treated of elsewhere. The most favorable 
forms of peritonitis are evidently the local, and especially those occurring 
in parts which are susceptible of removal. 

Treatment. — Evidently the most urgent indication is to relieve pain, 
and the measures employed for this purpose fortunately have a tendency to 
check the inflammation. Many remedies will relieve pain, but an opiate is 



HEBXIA OF THE ABDOMEN. 809 

preferable, because it is best, at least after one or two evacuations, to keep 
the bowels checked, and this an opiate accomplishes. A child of eight years 
may take one-fourth of a grain of opium or 5 drops of deodorized tincture of 
opium every two hours until the pain ceases or the physiological effects of the 
drug begin to be manifested by contracted pupil, stupor, and slow respiration. 
The opiate appears to be absorbed slowly, and it is the common belief that ab- 
sorption is slower in a case of peritonitis than in one not affected by this dis- 
ease. It is better, as a rule, to avoid subcutaneous injections of an opiate in 
children, since a dangerous stupor may suddenly occur from this treatment. 
Given by the mouth and its effects carefully observed, if the pain becomes 
less the intervals between the doses should be lengthened. 

If the vomiting be persistent, it may be necessary to employ rectal sup- 
positories. In all cases local treatment over the site of inflammation is 
required. A light poultice of one part of ground mustard and twenty of flax- 
seed, between two pieces of muslin so moist as to wet the hand in holding it, 
and as thin as the pasteboard covers of a book, may be employed, or a flax- 
seed poultice may be applied with the following on its under surface : 

01. caryophylli, sjij ; 

01. camphoratee, ,§iij. — Misce. 

Or hot water in a rubber bag may be used. 

Some physicians recommend cold applications over the abdomen in cases 
of acute peritonitis. Broken ice should be mixed with bran in about equal 
quantity, and applied over the abdomen if it give most relief. Generally, 
according to my experience, if the temperature of the patient reach or exceed 
103° F., the cool applications give most relief and should be preferred. If it 
be below 103°, the warm applications best satisfy the patient and should be 
used. 

Vomiting, flatulence, and eructations of gas are often symptoms which 
cause considerable distress. In such cases the most success attends the fol- 
lowing mode of treatment: A flexible No. 12 catheter is introduced six, per- 
haps eight, inches through the rectum, and half a pint of predigested milk, 
with half a pint of hot water to which two teaspoonfuls of Rudisch's predi- 
gested extract of beef are added, should be cautiously injected. The expul- 
sion of gas and undigested matter will be useful in relieving the distention, 
and what remains will be useful in sustaining the strength, especially if one 
or two teaspoonfuls of brandy be added to it. 



CHAPTEE XIV. 

HEKNIA OF THE ABDOMEN. 

Inguinal hernia consists in the protrusion of the abdominal viscera cov- 
ered by the peritoneum in the course of the inguinal canal, the channel 
by which the spermatic cord passes through the abdominal muscles to the 
testis. 

Several forms are recognized, which depend chiefly upon the varying rela- 
tions of the peritoneum. They have been explained as follows (T. Holmes) : 

(a) In congenital inguinal hernia the process of peritoneum which passes down 
with the cord, funicular process, remains freely open ; the general cavity of the 



810 



LOCAL DISEASES. 



peritoneum is therefore identical with that of the tunica vaginalis testis forming the 
hernial sac, the bowel contained in which is in direct contact with the testicle (Fig. 
213). 

(6) The condition of the parts in an infantile hernia are as follows : The tunica 
vaginalis, 1 (Fig. 214), is closed above, at or near the external inguinal ring, but 



Fig. 213. 



Fig. 214. 





Congenital inguinal hernia. 



Infantile hernia. 



its funicular portion is open : the bowel in the hernial sac lies behind this funicular 
portion, and is represented in the diagram as having made its way between the 
funicular process and the cord ; the relation of the sac to the cord seems, however, 
to be variable ; the bowel is covered in cutting down from the skin by three layers 
of peritoneum — viz. 1 and 2, the opposite surfaces of the funicular process, and 3, 
the anterior layer of the peritoneal hernial sac. 

(c) In the encysted form (Fig. 215) of infantile hernia the bowel, instead of 
passing behind the closed funicular process, has distended the membrane which 
closes its upper end, and has pushed itself into the funicular process, the upper or 
back wall of which envelops it ; in this case, therefore, the hernial sac is furnished 
by the funicular process itself, and only two layers of peritoneum cover the intes- 
tine. 

(d) In the common scrotal hernia (Fig. 216) the tunica vaginalis is seen behind 



Fig. 211 



Fig. 216. 





Encysted form of infantile hernia. 



Common scrotal hernia. 



and below, and is represented as distended with a certain amount of hydrocele fluid, 
but quite distinct from the hernial sac. 

(e) Partial obliteration of the funicular process illustrates the formation of cysts 
in the cord, encysted hydrocele of the cord (Fig. 217) : the cavity of the tunica 
vaginalis testis is closed at c : the funicular process is also separated from the peri- 
toneal cavity at a, the situation of the abdominal ring ; there is also another septum 
at 6. When one or more of these septa are absent or imperfect various conditions 
occur. 



HERNIA OF THE ABDOMEN. 



811 



(f) In the formation of the hernia into the funicular process of the peritoneum 
(Fig. 218) the septum or obliteration at c is absent, so that the tunica vaginalis is 



Fig. 217. 



Fig. 218. 





Cysts of the cord ; encysted hydrocele. 



Hernia into the funicular process. 



open as high as the septum, b, which is imperfect or has given way from some acci- 
dental cause ; in the diagram the septum at the external abdominal ring, a, is drawn 
as being widely open, but strangulation may occur either in the septum at b, some- 
what lower down, or at both. 

The symptoms and appearances of inguinal hernia are generally suffi- 
ciently characteristic, but even in the most marked case it is important, 
by a formal inquiry and the recognized tests, to distinguish it from differ- 
ent affections which occur in these organs and tissues. 

The more noticeable are hydrocele ; inflammatory affections and other 
diseases of the testis, cord, and their coverings ; of inguinal and lymphatic 
glands ; malpositions of the testis. 

Femoral hernia is so rare in children as not to require notice. Femoral 
must be distinguished from inguinal hernia by its position below Poupart's 
ligament ; from abscess ; from an enlarged gland and an enlargement of the 
femoral vein ; from tumors at this point. 

Umbilical hernia occurs at the point where the umbilical vessels pass 
through the abdominal wall ; it exists anterior to the period when cicatrization 
is complete, which varies in different infants, but in general requires several 
months. When the parts which fill the aperture are firmly cicatrized, this 
point of the wall is firmer than surrounding parts, 
owing to the condensation of the cicatrix and the Fig. 219. 

peculiar arrangement of the fibres of the trans- 
versalis fascia (Fig. 219). 

In infants the protruding viscus pushes before it 
that portion of the parietal peritoneum lying imme- 
diately behind the aperture in the linea alba, through 
which the umbilical vessels enter the abdominal 
cavity ; the hernial sac thus formed, before the 
closure of the ring is effected, may pass into the 
connective tissue of the cord itself before that struc- 
ture has separated ; after the separation of the cord 
the hernial sac may be protruded in consequence of 
the umbilical aperture remaining imperfectly closed, 
when it is covered only by the integuments ; in the 
youth the hernia may escape through a partially 
closed ring, which it dilates by continual pressure ; in the adult the fibres of the 
linea alba may become separated by stretching, owing to the pressure within, and 
the hernia escape at the site of the once-closed ring or in its vicinity (Fig. 219). 




Fascia at umbilicus. 



812 LOCAL DISEASES. 

The hernia begins by forming a soft, projecting ovoid tumor at the navel ; 
at first it may be reduced by pressure, when a small hole is felt with very 
sharp and rigid edges ; if the finger is removed, the skin either remains re- 
laxed in the fossa of the navel or it is slowly projected forward; as the dis- 
ease progresses the protruding viscus descends lower and lower, so that the 
broadest part lies below the mouth of the sac ; the tumor varies much in 
form, the transverse diameter being sometimes greater than the vertical ; 
occasionally it is pyriform, and seems suspended or spread out like a mush- 
room (Fig. 220) ; again, its base is nearly as large as its body ; in infants the 




Point of 
attachment of cord. 
Congenital umbilical hernia. 

hernia usually contains intestines, but in the adult omentum is generally 
added, and sometimes the stomach ; the coverings, usually very thin and 
often inseparably united, are the integument, some fat, the internal abdominal 
fascia, the sac ; the body of the sac is usually very delicate, but stronger 
near and at its orifice, around which the tissues form a firm, resisting, unyield- 
ing band ; the mouth of the sac is often large in proportion to the bulk of 
the protrusion. This hernia has been overlooked in very corpulent persons, 
and proved fatal by strangulation. 

The treatment of hernia should first be palliative. The truss is the 
first appliance to be resorted to in reducible hernia ; it should be applied 
immediately that the disposition to the formation of rupture is detected, with 
a view to procure adhesions of the serous surfaces : the rule applies to both 
sexes and all ages, the only exception being a misplaced testis. The effect 
of such pressure is to approximate the sides of the mouth of the sac, prevent 
the descent of the bowel, and lead to contraction and final obliteration of the 
hernial sac. As the commencement of a radical cure by truss-pressure dates 
from the last time the bowel or omentum came into the sac, it is of the first 
importance to prevent the hernia from ever coming down. About 15 to 20 
per cent, may be cured by judicious and persistent truss-pressure. 

DeGrarmo reported a cure of one-fourth of his cases by the truss in a 
total of 1000 treated ; he believes a large percentage of cases under middle 
life curable by mechanical means. 

Inguinal hernia requires a truss-pad that does not press upon or interfere 
with the circulation or other functions of the spermatic cord. Not uncom- 
monly the cord becomes jammed by the downward pressure of the truss-pad 
upon the crest of the pubic bone below, causing pain and uneasiness along 
the cord and in the testicle ; the latter slowly enlarges if the pressure be con- 
tinued, effusion takes place in the tunica vaginalis, and a hydrocele or a 



HERXIA OF THE ABDOMEN. 813 

hydro-sarcocele is gradually formed, or the pressure upon the spermatic 
origin of the cord gives rise to varicocele. It is of great importance to pro- 
tect those who, from hereditary tendency or weakness of the abdominal walls, 
are predisposed to rupture. 

For this purpose a broad band with a suitable pad (Fig. 221) may be worn 
(Fig. 222). It should consist of stout elastic web, which passes round the body, 

Fig. 221. Fig. 222. 





Band and pad applied. 

and it is attached to the pad in front by metallic loops engaging studs on the pad ; 
elastic bands pass from the body-band, under the limbs, to studs upon the rupture- 
pads. 

The bearing of the surface of the pad should be flat, the edge rounded off, the 
shape being an oblique oval. The best substance for the pad is vulcanite, and it 
should be maintained in position by a side-spring which encircles the body midway 
between the trochanter and the anterior superior iliac spine 5 sometimes it is neces- 
sary to wear a perineal band which buttons in front, but this may be dispensed 
with when the truss has accommodated itself to the shape of the body. A great 
variety of trusses may be found, but unless they conform in construction to the 
principles given they will fail to meet the indications. 

Femoral hernia requires that the truss-pad protect the crural ring by 
pressure over Poupart's ligament, and also press upon and fill the saphenous 
opening without pressing downward so as to obstruct the saphenous vein. 

Umbilical hernia, if congenital, should at first be treated with a piece of 
lint wrapped around a penny piece and kept on with a light flannel bandage, 
lightly swathing the infant's body, and kept from chafing by powdered 
starch. 

This form of hernia in the infant requires persistent efforts to close the opening 
by the following dressing : Apply a flat pad of any soft and tolerably firm material, 
moulded to the shape of the parietes and extending beyond the 
margin of the opening (Fig. 223) ; maintain it in position by Fig. 223. 

adhesive strips or by a broad elastic band properly padded ; 
remove the apparatus frequently to preserve cleanliness and 
prevent chafing, the finger being applied meantime to the open- 
ing. Radical cures have been effected by the truss. In the Umbilical 
adult this hernia is best retained by a truss with a wooden 
block slightly convex on its abdominal surface and secured to an elastic spring 
encircling the body ; if the hernia has become irreducible, apply a hollow, cup- 
shaped, well-padded truss. Obstruction from accumulation of stercoraceous matters 
frequently occurs in irreducible umbilical hernia, with severe constitutional dis- 
turbance, but without positive strangulation ; this condition is best overcome by the 
free administration of aperient enemata. 

The radical treatment of hernia should be undertaken when palliative 
treatment has failed, Of the many different operations devised, few are 
absolutely free from danger, and none are always ultimately successful. In 
determining the question of the propriety of an operation every case must 
be studied by itself, and the decision should depend upon the condition of 
the hernia, the health of the patient, and the risk incurred. 




814 LOCAL DISEASES. 

The following method of operation for inguinal hernia is advised : The 
external surfaces having been made aseptically clean, make an incision the 
centre of which is over the external abdominal ring ; the dissection is con- 
tinued until the sac is exposed. While it is important to be careful, owing 
to the peculiar delicacy of the structures in children, the operator may be so 
cautious as to tear and bruise tissues needlessly. The sac must now be care- 
fully separated from the cord and freed from all connections to a point within 
the internal ring, this latter being effected by the end of the index finger. 
The sac, being empty, is drawn down so as to be quite tense, and then firmly 
tied with strong carbolized silk as high up as possible within the internal 
ring. The fundus is next cut off about half an inch below the ligature, and 
the stump is pushed into the abdomen. Ball twists the sac with strong for- 
ceps, making four or five complete revolutions, then ligates the highest part 
of the twisted pedicle with catgut ligature and cuts away the mass. The 
next step in the operation is to raise the cord, and close by firm suture the 
internal ring from below upward. This should be done with carbolized silk 
and in such manner as to bring the conjoined tendon in contact with Pou- 
part's ligament. In order to bring these margins in firm contact, so as to 
secure a complete closure of the canal and internal ring, the best suture is 
that of the shoemaker, which gives the support of a double suture. The 
old canal and the internal ring having been closed, the cord is placed in posi- 
tion and the external wound closed. No drainage is required, and the exter- 
nal dressings must be antiseptic. Owing to the difficulty of keeping the 
wound of a child clean, Grerster of New York closes the neck of the sac and 
packs the wound with iodoform gauze, and thus treats it as an open wound. 
The radical operation for femoral hernia in children has rarely been 
required. Umbilical hernia is so generally relieved by a very simple pad 
as to have attracted little attention. Xota (Marcy) reduces the hernia and 
closes the ring with the finger ; while the sac is held firmly by an assistant, 
the operator winds a rubber tubing, one-eighth of an inch thick, three or 
four times around the neck of the sac tightly, and then ties the ends secure 
with a silk ligature. The whole is covered with cotton. In ten or twelve 
days the mass sloughs off, and the surface is dressed with iodoform and car- 
bolized cotton. The wound closes in four or five days. Xota has operated 
successfully on 18 cases. 

A strangulated hernia in a child does not differ from that in an adult in 
its management. The practitioner must first examine to determine the kind 

and variety ; its duration ; the hour at 

Fig. 224. which vomiting commenced ; the varia- 

Distended and ^t/\ Collapsed and tions in the composition of the fluid 

congested wk%]\ bloodless ejected: the usual size of the tumor; 

its bulk before vomiting; the changes 
during this stage ; the pain, whether 
local or extending into the abdomen with 
or without manipulation; the condition 
i\ eck of sac. Amk ' Jlk\ of its coverings: its probable contents: 

the treatment already pursued. The 

first step in the treatment is to endeavor 

to displace the hernia from its abnormal 

A strangulated hernia. position and pass it through the orifice 

of the sac into the peritoneal cavity. 
Before vomiting occurs abstain from manipulation of the tumor until other 
remedial measures have been tried ; place the patient on the back, with 
knees flexed and pelvis raised, and apply warm fomentations over the region 
of the mouth and neck of the sac ; if urgent symptoms do not arise, a few 




HEX XI A OF THE ABDOMEN. 



815 



Fig. 225. 



hours may be allowed to elapse to afford time for this treatment to take 
effect. Other measures have been employed to assist in reduction, with 
occasional benefit, as cold to the hernia ; reversing the trunk by keeping the 
head nearest the ground and the pelvis upward. Anaesthetics exert a power- 
ful influence over the causes preventing reduction. During the administra- 
tion of the anaesthetic taxis should be employed. This is a method of manip- 
ulation, and must be practised as follows : Place the patient in a position to 
relax all abdominal muscles which contract around the mouth of the sac ; 
fix as far as it is possible the mouth and neck of the sac with the fingers of 
one hand, whilst the fundus of the tumor is held in the palm of the other, 
the object being to dilate the mouth of the sac and diminish the bulk of the 
protrusion, the fact being borne in mind that irreparable injury is frequently 
inflicted upon the herniated bowel by violence, and that the danger of mis- 
chief by the use of the taxis increases in proportion to the length of time 
the bowel has been strangulated. As soon as the voluntary muscular con- 
traction ceases, make gentle and well-preconcerted pressure, and, if the taxis 
succeed, the tumor will gradually become softer or less elastic, smaller, and 
of different shape, until it escapes from the embrace of the mouth of the sac ; 
taxis, if not already abandoned, must always be discontinued altogether when 
it is certain from the vomited fluids that there is regurgitation of the contents 
of the duodenum and jejunum. 

The failure of the taxis necessitates the liberation of the hernia by the 
operation of herniotomy. 

An inguinal hernia which has resisted well-directed taxis must be at once 
liberated by division of the stricture. This operation should be performed 
with careful attention to all of the details required in the use 
of antiseptic dressings. Provide an ordinary hernia-knife, a 
common scalpel, probe-pointed bistoury (Fig. 225), forceps, di- 
rector, carbolized sponges, carbolic water 1 to 20, bichloride 
solution for irrigation, and carbolized gauze. Place the patient 
on a firm, low table ; shave the parts and wash them with bi- 
chloride solution ; give the anaesthetic fully. 

If the hernia is an oblique inguinal, raise the shoulders and 
slightly flex the thigh of the affected side, and make an incision 
through the skin over the neck and body of the tumor, its upper ex- 
tremity being nearly midway between the anterier superior spinous 
process of the ilium and the tuberosity of the pubes, about one inch 
and a half above the level of Poupart's ligament, and its lower about 
the middle of the scrotum. This incision exposes the intercolumnar 
fascia which forms the first and thickest covering of the sac ; divide 
this fascia after raising with forceps or on a director, when the cre- 
master muscle will be exposed, which must be cut in a similar man- 
ner, and this incision lays bare the sac. The division of these layers 
often causes great embarrassment and delay, for the operator, expect- 
ing to see the sac itself when he has divided the integuments, mis- 
takes the thickened covering and the cremaster muscle for the hernial 
sac, and cuts the fascia with extreme caution, fibre by fibre. Open 
the sac with exceedingly great care to avoid including the walls of 
the bowel, either seizing the sac with forceps (Fig. 22G) or raising it 
between the thumb and fingers. Make an opening sufficiently large 
to admit a grooved director with the scalpel, the sharp edge of which 
is directed laterally, the side of the blade being placed nearly flat on 
the tumor ; divide the sac on the director, pressed firmly against its inside (Fig. 
227). Make slight pressure upon the sac to return its contents into the abdomen : 
if reduction be impracticable, open the sac sufficiently to reach its orifice easilv : 
pass the index finger along the anterior surface of the protrusion upward toward 
the mouth of the sac, when the stricture will be encountered : the palm being- 
upward, pass the hernia-knife flatwise along the finger (Fig. 228) or on a grooved 



Probe-pointed 
bistoury. 



816 



LOCAL DISEASES. 



director through the mouth of the sac ; turn the knife so as to cut parallel with 
the linea alba, and divide the structures in contact with it sufficiently to allow 

Fig. 226. Fig. 227. 





Dissection of hernia. 



Introduction of director. 




Finger as director in operation for hernia. 



Fig. 229. 



the ungual phalanx to pass freely into the abdominal cavity. Carefully examine 
the protruded intestine to determine whether the brown color which it assumes 
under strangulation lessens or disappears, the proof of a return of circulation ; 

the intestine should also be pulled 
down a little to examine the part 
immediately compressed by the 
stricture ; the veins on the surface 
may be emptied by pressure and 
their sudden filling noted ; if the 
intestine appears to have free cir- 
culation, relax the parts by posi- 
tion, and directly but gradually 
return it, replacing about an inch 
at a time, and securing each part 
with the fingers until the whole is 
returned into the abdomen. The 
contents of the hernial sac should 
now be returned : all violence and 
improper haste should be guarded against, for the intestine is tender and will easily 
tear at the strictured part. Clear the parts of blood, irrigate with bichloride solu- 
tion 1 : 5000, nicely adjust the sac and its 
coverings, introduce a drainage-tube at the 
upper angle, and stitch all opposing tissues 
together with a continuous suture, in such 
manner as to firmly close the would. Bring 
the edges of the wound together with in- 
terrupted sutures (Fig. 229). Dust the sur- 
face with iodoform, and apply iodoform 
dressings with the spica bandage to retain 
them in position. 

The important feature of the after- 
treatment is the diet, which should be 
farinaceous, with milk ; opium should 
be used when required ; the bowels are 
often relieved spontaneously, but if they 
remain inactive and any discomfort 
arises, give an enema of warm water 
or gruel with common salt or a little 
castor oil ; if thirst is distressing, give 
ice ; stimulants are often required soon 
after the operation, but should be given 
in small quantities, and the addition of 
opiates is frequently very useful. 




Incision for inguinal hernia, stitched, show- 
ing the position of the drainage-tube at 
the outer angle of the wound. 



HEBXIA OF THE ABDOMEN. 



817 



Fig. 230. 



Umbilical hernia, strangulated, differs from other hernias in this, that too 
much stress cannot be laid upon the protracted and judicious employment of 
taxis, owing to the great fatality of operations upon this hernia. Place the 
patient on the back ; give an anaesthetic : as the tumor has descended, if at 
all bulky, draw it away from the ring, press its contents directly upward and 
backward in a direction opposite to that of the displacement. Should the 
taxis fail and the symptoms not be urgent, try the effects of a full anodyne 
and cold or warm applications. These efforts having failed, proceed to ope- 
rate antiseptically : 

Select a scalpel and director ; bearing in mind the thinness of the external 
coverings, particularly in recent cases, make a 
J_-shaped incision (Fig. 230), the vertical limb 
being carried nearly an inch above the upper 
extremity of the tumor, directly in the line of 
the linea alba ; raise successive layers on the director 
down to the sac, which must, if possible, be left intact, 
owing to the great danger of fatal peritonitis if it is 
divided. Seek the seat of stricture, which is generally 
found at the upper margin of the ring ; carry the knife 
upward upon the finger, and divide the stricture to the 
requisite extent : draw the protruded parts somewhat 
downward to liberate them from their confinement, 
and gently replace them in the abdomen — first bowel 
and then omentum. If the constriction is within the 
sac. the latter must be opened, the incision being as 

small as possible. When the hernia is irreducible leave the protruded structures, 
after the division of the stricture, in their extra-abdominal situation. 
52 




Incision in operation for 
umbilical hernia. 



SECTION IV. 
DISEASES OF THE RESPIRATORY SYSTEM. 



CHAPTEE I. 

CORYZA. 



The term " coryza " is applied to inflammation of the Schneiderian mem- 
brane. It is acute or chronic. The acute form is primary or secondary. Acute 
primary coryza is common in infancy and childhood. Its usual cause is 
exposure to currents of air, to cold, and especially to sudden changes of tem- 
perature, from warm to cold. The cause is the same as that in the ordinary 
forms of bronchitis. The two diseases frequently indeed coexist, occurring 
from the same exposure. The inflammation in such cases commences upon 
the Schneiderian membrane immediately upon the operation of the cause, 
and soon after extends to the bronchial tubes. Acute coryza may also be 
produced by the inhalation of irritating vapors, hot air, or dust, and also by 
the presence of a foreign body, as a button or bean, in the nostril. 

Secondary coryza is commonly due to a specific cause. The diseases in 
connection with which it occurs are influenza, whooping cough, measles, 
scarlet fever, diphtheria, and constitutional syphilis. In the infant coryza is 
one of the first manifestations of inherited syphilitic taint. 

Acute primary coryza ordinarily abates in from one to two weeks. The 
secondary form gradually declines, in most cases, when the primary affection 
on which it depends is cured. Syphilitic coryza is more protracted than the 
primary form or than that accompanying the eruptive fevers. Some children 
are so liable to coryza that it occurs whenever they take cold. Occasionally 
it is so frequently renewed in the winter months that it resembles the chronic 
form of the disease. 

Acute coryza is commonly dependent on a dyscrasia, usually the syphilitic 
or strumous. The dyscrasia is indicated by pallor, flabbiness of the flesh, and 
liability to glandular swellings. Certain cases take their origin in the nasal 
catarrh of the exanthematic fevers, the local affection continuing after the 
constitutional disease has declined. Chronic coryza sometimes occurs in chil- 
dren who appear otherwise in good health. It is probable that in such cases 
there is a dyscrasia of which the coryza happens to be the sole manifestation. 
If the coryza appear on one side, be persistent, and the discharge be muco- 
purulent and offensive, probably a foreign substance, as a button, has been 
pushed into the nostril. Obviously, if present, the coryza will continue until 
the substance is removed by the forceps or otherwise. 

Anatomical Characters. — The alterations which the nasal mucous 
membrane undergoes when inflamed vary considerably in different cases. In 
the simplest and most common form of coryza this membrane is sometimes 
in patches, sometimes generally reddened, thickened, and softened. Its papillae 
are prominent, producing an inequality of the surface. Ulcerations are not 
common in simple acute coryza, but they sometimes occur in the chronic 
form. 

In diphtheria, and sometimes in scarlet fever and variola of severe type, 
the coryza is pseudo-membranous, and when it presents this form it is com- 
818 



CORYZA. 819 

monly. but not always, associated with pseudo-membranous angina or laryn- 
gitis. It is commonly diphtheritic wherever diphtheria prevails, and is very 
prone to end in systemic infection unless promptly and properly treated. 

Symptoms. — The constitutional symptoms are mild or severe according 
to the gravity of the inflammation. If the coryza be acute and pretty general, 
there is febrile movement, with thirst and loss of appetite. Frontal headache 
is common, from the proximity of the inflammation to the head or its exten- 
sion to the frontal sinuses. Sneezing is the first symptom in many cases of 
acute coryza. As the inflamed membrane swells more or less obstruction 
occurs to respiration. The breathing is noisy, especially during sleep, and 
in severe cases the patient is compelled to breathe through the mouth. If 
there be much obstruction to respiration, the suffering of the patient is con- 
siderable, from the sensation of fulness in the nostrils, the headache, and the 
muscular effort required in each respiratory act. 

In the commencement of coryza the patient experiences a sensation of 
dryness in the nostrils, which is soon succeeded by a thin discharge of a 
serous appearance. In the course of a few hours the secretion becomes 
thicker. It is muco-purulent, and remains such till the disease begins to 
decline. Inspissated mucus and crusts are liable to collect within the nos- 
trils and around their orifice in chronic coryza, and sometimes also in the 
acute disease if the discharge be not abundant. These crusts increase the 
difficulty of breathing. Often the acridity of the discharge is such that 
the skin of the upper lip and around the nostrils is excoriated. 

Prognosis. — Uncomplicated catarrhal coryza rarely terminates fatally. 
It is only dangerous in young nursing infants, in whom it may prevent 
proper traction of the nipples. Coryza accompanying the eruptive fevers, 
although it may increase the suffering, does not materially increase the 
danger. Syphilitic coryza subsides when the system is sufficiently affected 
by antisyphilitic remedies. Chronic coryza is sometimes very obstinate. It 
may continue for months or years, giving rise to a constant though not 
abundant discharge. 

Treatment. — Common mild attacks of coryza require little treatment. 
The bowels should be kept open and the body should be warmly clothed. 
Inunction of the nostrils is a popular remedy, and it seems to give some 
relief. The most successful mode of treating simple catarrhal coryza, as 
well as ulcerative or membranous, is by nasal irrigation by means of a 
hand-atomizer or syringe, used hourly or every two hours, with one of the 
following remedies: Squibb's peroxide of hydrogen (11 vol.) rendered 
alkaline and reduced by water at the time of use. The mother or nurse 
should first employ it upon herself, and dilute it still more if necessary (see 
art. Diphtheria). Another good nasal wash is Seller's tablet, one tablet to 
six tablespoonfuls of water. A 5 per cent, solution of common salt in 
warm water injected into the nostrils with a small syringe aids materially 
in removing the muco-pus which obstructs the respiration and in establishing 
a healthier state of the inflamed surface. The following formula will be 
found useful in most cases of this form of coryza : 



R. Acidi borici, 


35; 


Sodii biborat., 


3ij ; 


Aquae, 


5 vii J' 



R. Sodii chloridi, £j ; 

Sodii biborat., £ij ; 

A quae, Oj. — Misce. 

Half a teaspoonful, used warm, should be injected into each nostril several times 
daily, with the head thrown backward. 



820 LOCAL DISEASES. 

The treatment proper for pseudo-membranous or diphtheritic coryza is 
detailed in our remarks on the therapeutics of diphtheria. Chronic coryza, 
since it depends upon a dyscrasia of which it is one of the local manifesta- 
tions, requires remedies appropriate for the blood disease. Scrofula needs 
the syrup of the iodide of iron and cod-liver oil. The various ferruginous 
preparations, as wine of iron, tincture of the chloride of iron, iron lozenges, 
and the vegetable tonics are also more or less useful. The diet should be 
nutritious and plain, and out-door exercise and, if possible, country life should 
be enjoined. 

If the dyscrasia be syphilitic, similar invigorating measures are required, 
and mild mercurial inunctions to the nasal surface are especially useful. The 
following, which has been largely employed in the Out-door Department at 
Bellevue, is one of the best ointments for such cases, and its alterative effect 
renders it also useful for strumous coryza : 

R. Ung. hydrarg. nitratis, ^ij ; 

ITng. zinci oxid., ^ij. — Misce. 

To be thoroughly applied to the Schneiderian membrane by a swab or camel's- 
hair pencil three or four times daily. Recently it has been modified by the 
substitution of Squibb's 5 per cent, oleate of mercury in place of the citrine 
ointment. If the coryza have a distinctly syphilitic origin, the application 
of a 2 or 3 per cent, oleate of mercury will fully meet the indication and be 
followed by improvement. 

Meigs and Pepper recommend the following ointment in chronic coryza, 
to be applied at night after the use of injections through the day : 

R. Unguenti hydrargyri nitratis, gss ; 
Extracti belladonna, gr. x ; 

Axungiae, ^ss. — Misce. 

Astringent injections into the nostrils are not often required in the treat- 
ment of the various forms of coryza ; but occasionally, if the discharge be 
protracted and abundant, weak astringent applications may be beneficial, as 
two or three grains of nitrate of silver or of alum or tannin to the ounce of 
water. It should be borne in mind that washes for the nasal surface should,, 
as a rule, be employed tepid. 



CHAPTER II. 

LAKYXGITIS. 

Catarrhal Laryngitis. 

Acute catarrhal laryngitis occurs at all ages, but it is so common in 
infancy and childhood that it is proper to treat of it in a work relating to 
the diseases of these periods. Like other inflammatory affections of the air- 
passages, it is most common in the cold months or when the weather is 
changeable. Its usual cause is, therefore, exposure to cold. Protracted and 
violent crying and the inhalation of acrid vapors are occasional causes. 
Catarrhal — or, as it is sometimes designated, simple — laryngitis also occurs 
in connection with certain constitutional diseases, among which may be men- 
tioned measles, scarlatina, and variola. Laryngitis is also a common accom- 



LARYNGITIS. 821 

paniment of bronchitis and broncho-pneumonia, though its symptoms are 
liable to be obscured by those of the graver disease. It often likewise accom- 
panies pharyngitis, due to extension of the inflammation. 

Symptoms. — Catarrhal laryngitis produced by the impression of cold is 
commonly preceded and accompanied by coryza. The initial symptom is 
chilliness, followed by sneezing and the discharge of thin mucus from the 
nostrils in consequence of irritation of the Schneiderian membrane. 

The commencement of laryngitis is indicated by hoarseness, which is 
apparent when the child cries or, if old enough, when it attempts to speak. 
There is often in severe cases complete loss of voice, so that speech above a 
whisper is impossible. I have noticed this most frequently in the laryngitis 
which accompanies measles. A cough occurs which is at first dry and 
husky, but becomes loose in the course of a few days. Expectoration is 
scanty, unless the inflammation have extended to the trachea and bronchial 
tubes. 

This disease is often accompanied by soreness of the throat, noticed in 
the act of coughing or when the larynx is pressed with the finger. In laryn- 
geal catarrh, when uncomplicated, the respiration remains nearly natural and 
the pulse is but little accelerated. In mild cases the nature of the disease is 
often not apparent, as long as the child remains quiet, in consequence of the 
absence of symptoms, but the character of the voice when it cries or speaks, 
or of the cough, reveals at once the nature of the affection. 

Acute laryngeal catarrh subsides in from one to two weeks. Occasionally 
it lasts three or four weeks before the symptoms entirely disappear. Death, 
which is rare, is due to some complication. 

Chronic laryngitis is much less frequent than the acute form. Its ana- 
tomical characters are similar to those in other chronic inflammations affect- 
ing mucous surfaces — to wit, thickening and more or less infiltration of the 
mucous membrane, increased proliferation and exfoliation of the epithelial 
cells, and increased functional activity of the muciparous follicles. 

In the adult, chronic laryngitis is common as one of the lesions of the 
syphilitic or tubercular disease. In the child, syphilitic and tubercular laryn- 
gitis is more rare, but the latter sometimes occurs in connection with pulmo- 
nary or bronchial tuberculosis. Such patients are emaciated and have the 
ordinary symptoms of the tubercular disease. Chronic laryngitis also occurs 
in young children, usually infants, as one of the manifestations of the stru- 
mous diathesis. I have records of several such cases, mostly nursing infants. 
Some of these patients had mild bronchitis, but it was obviously subordinate 
to the laryngitis. Their respiration was noisy and harsh, continuing of this 
character several weeks and even months. The cough was also harsh and 
loud, conveying the idea of thickening and relaxation of the mucous mem- 
brane covering the vocal cords. Their respiration was not notably accelerated 
and the blood was apparently fully oxygenated, though the friends were often 
alarmed by the noisy breathing and cough. 

In this form of chronic laryngitis expectoration is scanty, the fever slight 
or absent, the appetite remains unimpaired, and the general condition of the 
child is good. From time to time exacerbations occur, and occasionally 
improvement is such as to encourage the hope of speedy cure ; but in the 
cases which I have seen there has not been complete intermission in the dis- 
ease till the final recovery. Those patients whom I have been able to follow 
through the disease have recovered in from three to four months or one year. 

Chronic laryngitis is to be distinguished from frequent attacks of acute 
laryngitis which are due to fresh exposures, and also from the laryngitis 
which is associated with bronchial phthisis. It is to be distinguished from 
protracted acute laryngitis, which sometimes does not entirely subside in less 



822 LOCAL DISEASES. 

than a month or six weeks, by its longer duration, the greater thickening of 
the inflamed membrane, and more noisy respiration. Often chronic laryngitis 
results from the acute disease, the inflammation being perpetuated by the 
struma or dyscrasia of the patients. 

Anatomical Characters. — In acute catarrhal laryngitis the mucous 
membrane of the larynx presents the usual appearances of mucous surfaces 
when inflamed — namely, redness and thickening. It is also more or less soft- 
ened. Ulcerations rarely, perhaps never, occur in acute primary laryngitis. 
When present in chronic laryngitis the ulcers are small and situated upon or 
near the vocal cords. Tubercular and syphilitic ulcers of the larynx are much 
more rare in children than in adults. The inflammation in simple acute laryn- 
gitis usually extends over the whole surface of the larynx and also to the 
upper part of the trachea. It may be pretty uniform or more intense in one 
place than another, and, like other mucous inflammations, it is accompanied 
by more or less proliferation and exfoliation of epithelial cells. In most cases 
of simple laryngitis, whether acute or chronic, the inflammation extends to 
the pharynx, producing redness and thickening, though generally moderate, 
of the mucous membrane which covers it. Examination of the fauces there- 
fore aids in diagnosis. 

In the adult cedema glottidis occasionally results from laryngitis. In the 
child there is little danger that this will occur, in consequence of the anatom- 
ical character of the larynx, since in early life the larynx contains but little 
submucous connective tissue, and therefore less submucous infiltration or 
exudation occurs during the inflammation. The structural changes occurring 
in catarrhal laryngitis of infancy and childhood relate almost exclusively to 
the mucous membrane. 

Treatment. — Primary and uncomplicated catarrhal laryngitis requires 
little treatment. Most cases do well by the employment of suitable hygienic 
measures, without medicine. Benefit is, however, derived from the use of 
demulcent drinks and an occasional laxative. A mixture of paregoric and 
syrup of ipecacuanha or the mist, glycyr. comp. or a small Dover's powder 
will relieve the cough. For restlessness a warm foot-bath is also useful. 
Inhalation of the spray of glycerin and water from the atomizer, or of steam, 
plain or rendered alkaline by the use of lime-water and a little bicarbonate 
of sodium, is also useful. In the N. Y. Foundling Asylum great benefit 
appears to be derived from the constant inhalation from a croup-kettle of 
the vapor of one ounce of turpentine to two quarts of water. Chronic 
laryngitis dependent on syphilis or tuberculosis requires the constitutional 
treatment which is appropriate for that disease. The chronic laryngitis 
which I have described as occurring chiefly in infancy, and which appears to 
be of a strumous character, is in most cases obstinate. The patient should 
be warmly clothed, and constant care should be taken that there be no 
exposure which would endanger taking cold, as this would produce an 
exacerbation of the disease and tend to counteract what had been gained 
by remedial measures. This form of chronic laryngitis is most satisfactorily 
treated by the application of the following ointment upon the neck directly 
over the larynx, and the internal use of cod-liver oil and the syrup of the 
iodide of iron : 

R • Plumbi iodidi, £j ; 

Ext. belladonna, 3j ; 

Lanolini, Jj. — Misce. 

Spasmodic Laryngitis. 

This is a common disease. It is also called false croup, in contradistinc- 
tion to true or pseudo-membranous croup, and by some Continental writers 



LARYNGITIS. 823 

stridulous angina or stridulous laryngitis. It should not be confounded with 
spasm of the glottis, which is a form of internal convulsions and is not 
inflammatory. It occurs ordinarily between the ages of two and five years. 
It is commonly a sporadic affection, but Rilliet and Barthez state that " it is 
incontestable that it may prevail epidemically." They express this opinion, 
not from their own observations, but chiefly from those of Jurine, made in 
the commencement of the present century. - 

Causes. — Children in some families are more liable to false croup than in 
others, so that an hereditary tendency to it must be admitted. The exciting 
cause in most cases is exposure to cold. False croup is not uncommon in the 
commencement of measles. Narrowness of the rima glottidis and an excita- 
ble state of the nervous system, both of which are common in early childhood, 
are predisposing causes. 

Symptoms. — Spasmodic laryngitis is ordinarily preceded for a day or two 
by a slight cough and fever, by symptoms of mild nasal catarrh, such as all 
children are liable to on taking cold. In exceptional cases these symptoms 
are absent and the disease begins abruptly. Singularly, it commences in 
most patients at night after the first sleep, between ten and twelve o'clock. 
The sleep is usually quiet and natural, but the child awakens with a loud 
barking cough. There is great dyspnoea, and the respiration is harsh or 
whistling, on account of the narrowing of the chink of the glottis from the 
swelling and tension of the vocal cords. The face is flushed and expressive 
of suffering. The child cries, moves from one position to another, wishes to 
be held or carried, seeking in vain for relief. The skin is hot, pulse acceler- 
ated, the voice hoarse or even whispering. After a variable period, usually 
from half an hour to two or three — not more than half an hour with proper 
treatment— these symptoms abate. The patient is then somewhat exhausted 
and falls asleep. The face is less flushed or even pallid, the heat abates, and 
the pulse is less accelerated. The cough, though less frequent, remains for 
a time barking or sonorous, and respiration, though greatly relieved, is not at 
once entirely natural, but it gradually becomes so. In many cases the spas- 
modic respiration and cough do not recur, but sometimes the attack is repeated 
once or more, especially during the subsequent nights. The symptoms vary 
greatly in intensity in different patients. 

As the attack declines the disease, losing its spasmodic character, becomes 
a simple inflammation. In some patients the abatement of the cough and 
restoration of health are rapid, but oftener the inflammation extends not only 
into the trachea, but also into the larger bronchial tubes, and a tracheo-bron- 
chitis remains, which gradually declines. 

The termination is not always so favorable. Spasmodic laryngitis is, in 
exceptional instances, the precursor of other serious affections, which may 
prove fatal. It has been stated that measles often begins with spasmodic 
laryngitis. Bronchitis, becoming capillary, may occur in connection with it, 
as may also pneumonia, and by either of these severe inflammations the 
prognosis may be rendered doubtful. A few cases have been recorded in 
which it was believed that spasmodic laryngitis was of itself fatal. In some 
of these the dyspnoea was extreme and persistent and was the cause of death. 
In a case reported by Rogery, on the other hand, the respiration became easy 
before death and the pulse more and more frequent and feeble. Death 
apparently occurred from exhaustion. It is not improbable that had careful 
post-mortem examinations been made in those cases of spasmodic laryngitis 
which have ended fatally, other lesions would have been discovered besides 
those located in the larynx, perhaps tracheo-bronchitis, with an accumulation 
of mucus in the larynx, producing suffocation, or perhaps in some of the 
cases congestion of the brain or lungs and serous effusion. 



824 LOCAL DISEASES. 

Anatomical Characters ; Pathology. — The opportunity does not 
often occur of determining the anatomical characters of spasmodic laryngitis. 
I have witnessed but one post-mortem examination. A little girl nine years 
old was taken on Friday night with cough and dyspnoea, indicating a pretty 
severe attack. The mother, acting through the advice of a friend, gave 
kerosene oil to her in considerable quantity. This was succeeded by obstinate 
vomiting and purging, which continued during Saturday and Sunday, and 
terminated fatally on Monday. At the autopsy we found uniform and 
intense hyperemia throughout the whole extent of the larynx and trachea 
and in the bronchial tubes, but there was no pseudo-membrane on the inflamed 
surface and but little mucus and pus. The solitary follicles of the intestines 
and Peyer's patches were tumefied, and the gastro-intestinal surface was 
injected in places. The cause of death was obviously the diarrhoea, appar- 
ently of an inflammatory character, and probably produced by the kerosene 
oil. The condition of the mucous membrane of the larynx was that which 
is ordinarily present in spasmodic laryngitis, though in some cases in which 
post-mortem examinations have been made the evidences of laryngeal inflam- 
mation were slight. Guersant relates a case in which the surface of the 
larynx seemed to be nearly in its normal state. Death in cases of slight 
laryngitis is due to causes which are independent of the larynx. In Guer- 
sant's case tuberculosis was present. 

There is, as has already been intimated, another and a more important ele- 
ment besides the inflammation in the pathology of spasmodic laryngitis — 
an element producing those phenomena which render it a disease distinct from 
simple laryngitis. I refer to spasm of the laryngeal muscles. This element 
pertains to the nervous system, so that spasmodic laryngitis is allied both to 
the neuroses and to inflammation. 

Diagnosis. — The disease for which spasmodic laryngitis is most fre- 
quently mistaken is pseudo-membranous croup. The friends, indeed, usually 
make this mistake in forming their opinion of the case before the physician 
arrives ; and there can be no doubt that many of the cases which have been 
published in medical journals as true croup were examples of this affection. 
The points of differential diagnosis are the following : True croup begins 
with symptoms which at first are slight, so as scarcely to arrest attention, 
but which gradually increase in intensity. The cough becomes more harsh 
and the respiration more difficult by degrees. This increase in the gravity of 
the symptoms occurs by day as well as by night. On the other hand, false 
croup, though preceded by symptoms of nasal catarrh, commences abruptly. 
The symptoms have from the first their maximum intensity, and the time at 
which it commences is at night. Again, the cough in spasmodic laryngitis 
possesses a loud, sonorous character, while in true croup it is harsh or rough 
from the presence of the membrane, and having, therefore, less fulness. 
The voice in spasmodic laryngitis may be hoarse, but it is not lost or is lost 
only for a short time. It afterward becomes natural or is slightly hoarse. 
On the other hand, in true croup the voice, from being natural at first, is 
gradually extinguished. In fatal cases it soon becomes whispering, and con- 
tinues such till the close of life ; in those that recover the voice remains 
hoarse several days. These differences are important, and if fully appre- 
ciated are in most instances sufficient to establish the diagnosis. Besides, in 
a large proportion of cases of true croup portions of the pseudo-membrane 
may be discovered on inspecting the fauces, and the faucial surface is deeply 
injected, while in spasmodic laryngitis there is, with rare exceptions, no 
false membrane upon the surface of the fauces and but a moderate amount 
of congestion. 



LARYNGITIS. 825 

Laryngismus stridulus or internal convulsions must not be confounded 
with this disease. It is not inflammatory, but purely spasmodic, suddenly 
commencing and abating — identical, it is believed, in character with tonic 
convulsions of the external muscles, but affecting the internal muscles of 
respiration. This disease has already been fully described. 

Prognosis. — Little need be added, as regards prognosis, to what has 
already been stated. While a favorable opinion in reference to the result 
may ordinarily be expressed, the physician should not forget the fact that 
death may occur. Symptoms indicating an unfavorable termination are — 
great and continued dyspnoea, not diminished by the proper remedial mea- 
sures : stridulous expiration as well as inspiration ; lividity of the prolabia 
and lingers : pallor and coldness of surface ; pulse progressively more 
frequent and feeble. Convulsions and coma may also occur near the close 
of life. 

Treatment. — The indications of treatment are twofold : first, to relieve 
the spasmodic action of the laryngeal muscles ; secondly, to cure the laryn- 
gitis. To meet the first indication a warm bath of the temperature of about 
100° should be employed as soon as possible after the commencement of the 
attack. The patient should be kept in it ten or fifteen minutes, in order to 
obtain its full relaxing effect. In mild cases a warm foot-bath may be suf- 
ficient. A second means is the use of an emetic, which should be simulta- 
neous with the bath. To children under the age of three years syrup of 
ipecacuanha should be given, in doses of one teaspoonful repeated in twenty 
minutes, till vomiting occurs. Children over the age of three years, unless 
of feeble constitution, are best treated by the compound syrup of squills in 
teaspoonful doses, or a mixture of this with syrup of ipecacuanha. It is not 
often necessary to give more than three or four doses, and sometimes one or 
two are sufficient to produce vomiting. 

In most cases by the use of the warm bath and the emetic the symptoms 
are rendered milder, and convalescence soon commences. 

Dr. R. R. Livingstone 1 reports a case of laryngitis treated by Squibb's 
ether. It is stated that portions of pseudo-membrane from one-eighth to 
three-fourths of an inch in length were expectorated ; but the symptoms 
certainly indicated a spasmodic element as decided as in spasmodic croup, 
and the benefit from the ether was apparently due to the relaxation of 
the laryngeal muscles which it produced. The treatment of the patient, 
who was two years old, was commenced by the administration by the mouth 
of half a teaspoonful of the ether, and followed by its inhalation. " In pre- 
cisely eight minutes from the time the patient commenced the inhalation the 
abnormal muscular exertion ceased ; a general relaxation took place ; the 
pulse (which had numbered 150) fell to 100." Ether, judiciously employed, 
will probably prove to be a useful remedial agent in spasmodic forms of 
laryngitis, whether or not it have any effect on pseudo-membranous forma- 
tions. A large majority of cases, however, recover speedily without its em- 
ployment or by the other measures recommended. 

Attention should always be given to the state of the bowels in spasmodic 
laryngitis ; if they are not well open a purgative should be administered. 
For those that are robust and with considerable febrile movement the saline 
cathartics are ordinarily preferable, as Rochelle salts, or a purgative dose 
of calomel may be administered. The cathartic should not be prescribed 
till the nausea from the emetic has subsided. By its derivative effect it 
tends to diminish the laryngitis, and in severe cases it may obviate the 
need of depletion by leeches. 

Inhalation of the vapor of hot water and the application of a sinapism 
1 American Journal of the Medical Sciences, April, 1867. 



826 LOCAL DISEASES. 

over the neck and upper part of the sternum, followed by an emollient poul- 
tice, are useful adjuvants to treatment. 

The most convenient and effectual way of employing vapor is, however, 
by the atomizer, and as the chief danger is that the inflammation may 
become pseudo-membranous, I am in the habit of using in the atomizer the 
officinal lime-water, its solvent action being increased by the addition of the 
sodium bicarbonate, two drachms to the pint. 

When the spasmodic element in the disease is relieved the case becomes 
one of simple laryngitis, and the general plan of treatment recommended for 
that malady is proper for this. Small doses of ipecacuanha or of one of the 
antimonial preparations, as the compound syrup of squills, not sufficient to 
cause nausea, should now be given at regular intervals. Phenacetin, given 
every third hour in doses of half a grain, one grain, or one and a half grains, 
is a useful remedy if the temperature reach 103°. Its effect should be 
watched, and it should be discontinued when its sedative influence on the 
circulation begins to be apparent. 

If, however, the disease do not speedily terminate by recovery, or more 
rarely by death, there is nearly always tracheo-bronchitis or a more serious 
affection coexisting with the laryngitis or following it, so that depressing 
measures should not be long continued. Expectorants of a stimulating cha- 
racter, as carbonate of ammonium, are required in the course of a few days, 
and in young and feeble children they should be given at an early period. 

The mode of treatment recommended above is appropriate for that large 
class in whom the inflammatory element predominates. In a smaller number 
of cases the nervous element predominates over the inflammatory, and the 
treatment should be in some respects different. Such children are usually 
pallid and of spare habit, having, indeed, the nervous temperament. They 
are liable to attacks of this disease, though generally of a mild form, on 
slight exposure to cold, and with a very moderate amount of inflammation. 
The treatment in these cases should be directed more to the nervous system. 
My plan has been in the treatment of such patients, after perhaps the use of 
a mild emetic, to give quinine, one grain three or four times daily to a child 
from three to five years old, prescribing at the same time a simple expector- 
ant and a mildly irritating application to the throat. The symptoms in these 
cases are not severe, and active measures are not required, though the peculiar 
cough continues longer than in the more inflammatory forms of the malady. 

The patient with spasmodic laryngitis should be kept in a warm room 
during the paroxysms, and should inhale an atmosphere loaded with 
moisture. 

Trousseau recommends a mode of treatment of spasmodic laryngitis which 
was first suggested by Graves of Dublin. It consists in the application 
underneath the chin, so as to cover the larynx, of a sponge soaked in water 
as hot as can be borne ; in ten or fifteen minutes it is repeated. This red- 
dens the skin, producing revulsion from the larynx. The hoarseness, 
dyspnoea, and cough diminish with this treatment, and some recover without 
other measures. 

In rare cases of spasmodic laryngitis the dyspnoea becomes so great, not- 
withstanding active treatment, that the life of the patient is in danger 
whether oedema glottidis or thickening and infiltration of the laryngeal 
mucous membrane be present. In these cases intubation with O'Dwyer's 
tubes will give prompt relief. Spasmodic contraction of the laryngeal mus- 
cles probably also occurs in these cases, increasing the dyspnoea. Recently, 
in the case of a child of about three years, the dyspnoea was so great in 
about three hours from the commencement that intubation was performed 
with immediate relief. 



LABYXGITIS. 827 

Guersant and others speak of the importance of prophylactic management 
of children who are liable to this disease. Attention should be given to the 
dress, so that there may be sufficient protection from atmospheric changes, 
and there should be an equable temperature of the apartments in which they 
reside. Children of a decidedly nervous temperament, in whom the slightest 
laryngitis is liable to be spasmodic, require additional prophylactic measures. 
They are pallid and in a more or less cachectic state. Such children are 
benefited by chalybeate and vegetable tonics and by exercise in suitable 
weather in the open air. 

Imperforate nose may be congenital ; it is then caused by a membrane 
stretched across the nostrils, or by firm fibrous tissue, or by simple continuity 
of the integument. In congenital closure the interference with respiration 
and sucking often requires an early operation. In most cases a simple in- 
cision carefully made through the obstructing membrane, and the opening 
maintained by strips of lint or a short elastic cannula, is sufficient. Some- 
times it may be desirable to excise a portion of the obstructing tissue. 
When there is no indication of the opening of the nostril, the adherent parts 
must be gradually and cautiously divided until the nasal canal is restored. 

Hemorrhage from the nose, epistaxis, is of very common occurrence in 
children, owing to the immense distribution of blood-vessels throughout the 
cavities, and the existence of cavernous bodies between the periosteum and 
mucous membrane of the turbinated bones. Bleeding may be spontaneous 
or result from injury, and when severe there is a rupture of vessels. The 
following are some of the more useful remedies : 

Place the patient in the sitting posture, the head inclined slightly forward ; re- 
move all articles from the neck which prevent the free flow of blood ; secure the 
most perfect possible state of rest of mind and body, and encourage quiet respi- 
ration without speaking or blowing the nose. The simple means are cold to 
the nose and forehead or to the back of the neck, elevation of the arms above the 
head, astringent injection or spray, as of alum, tannin, zinci sulph., mustard foot- 
baths. As, in a large number of cases, the bleeding spot is near the anterior and 
lower border of the septum, the bleeding may often be arrested by pressing the ala 
of the affected side against the septum in such a manner as to close the nostril and 
the front and upper part of the nose ; or the finger may be applied directly in the 
nostril ; or a compress of lint, tied with a string with which to remove it, may be 
introduced into the nostril ; wicks or strips of linen may be introduced through the 
nose to the pharynx, and they may be sprinkled with tannin or dipped in persul- 
phate of iron to increase their styptic qualities. Antipyrine in aqueous solution, 
1 : 30, is a safe and powerful haemostatic applied on lint ; insert as far as possible, 
and then compress the nose so as to bring the solution in contact with a large sur- 
face of mucous membrane. Cocaine applied in a 4 per cent, solution relieves con- 
gestion. Not unfrequently a careful examination will reveal a small ulcer just 
within the ala, from which the hemorrhage occurs. The application of the solid 
nitrate of silver will cause rapid cicatrization. If the child becomes anaemic from 
frequent losses of blood, the liq. ferri persulphatis in 3- to 5-drop doses in water is 
very useful. 

Foreign bodies are often introduced into the nasal cavities by children. 
The substances may remain long in the nasal cavities without causing any 
trouble, but, in general, their immediate effect is circumscribed inflammation, 
with purulent, bloody, and often fetid secretions. The diagnosis is made out 
from the history and exploration. If the history is doubtful, inspect the 
cavities, remembering that the foreign body may be covered with secretions; 
finally, explore with the probe, distinguishing, by the sensation, sound, and 
mobility, between the movable body and the bone. Early removal must 
follow detection of the body. Sneezing and the douche are sometimes 
effective. The most convenient instruments are thin, short, straight dressing- 



828 LOCAL DISEASES. 

forceps and small scoops. Care is requisite in seizing the body, lest it be 
pushed more deeply into the cavity. First apply a 4 per cent, solution of 
cocaine with a spray apparatus. 



CHAPTER III 



DISEASES OF THE LARYNX. 



Foreign bodies entering the larynx are arrested in its interior, or descend, 
according to their size, form, and weight. When arrested in the larynx, they 
may lodge in one of the ventricles or become fixed between the vocal cords. 
Occasionally they are arrested at the junction of the larynx and trachea. 
The first symptoms of the entrance of the body into the air-passages are 
usually severe and characteristic : the patient gasps for breath, coughs vio- 
lently, the face becomes livid, the eyes protrude, the body is contorted, and 
he is like one choked by the hand. If the body is lodged in the larynx, the 
symptoms will vary with its size and peculiarities. It may be so large as to 
prove fatal by suffocation, or so small, hard, and smooth as to cause but slight 
symptoms. Ordinarily there is aphonia, with pain and soreness, and uneasi- 
ness in that region ensues, with dyspnoea and a whistling sound in respiration ; 
at the same time there is absence of tracheal and bronchial disturbance. If 
the symptoms are not so urgent as to require immediate tracheotomy, apply 
a 4 per cent, solution of cocaine to the palate and pharynx preparatory to 
laryngoscopic examination. In fifteen minutes examine the larynx. If the 
body is lodged above or within the larynx, with properly curved forceps it 
may be seized and removed without pain. As a general rule, the trachea 
should be opened with as little delay as possible in every case in which a 
foreign body is certainly known to be retained in any part of the air-passages, 
for by this means the immediate safety of the patient is secured and subse- 
quent expulsion or removal aided. 

An anaesthetic should always be given when the symptoms admit of delay, but 
in many cases there is not a moment to lose, and the trachea must be opened at 
once ; even if the patient cease to breathe before this is accomplished, the operation 
should be completed and artificial respiration instituted and perseveringly main- 
tained. In those cases where the symptoms are so slight as to cause hesitation 
before adopting such severe treatment delay is dangerous, for an interval of calm 
constantly precedes the recurrence of urgent symptoms, and temporary freedom 
from distress, instead of contraindicating the operation, affords the best opportunity 
for its performance. In deciding as to the particular form of operation in any case, 
it must be borne in mind that while laryngotomy is simple, easy, and free from risk, 
it is not as applicable to early childhood as tracheotomy, on account of the very 
limited dimensions of the crico-thyroid space. 

Laryngotomy is performed as follows (Fig. 231) : Place the patient on a table 
with the head and shoulders properly elevated and firmly fixed (Fig. 232) ; feel for 
the thyroid cartilage at the lower border of which it is to be opened ; make an 
incision with a narrow scalpel along the centre of the larynx, from the top of the 
thyroid to the base of the cricoid cartilage ; this incision should be one and a half 
inches in length ; if the crico-thyroid artery bleed, it must be twisted or tied ; divide 
the crico-thyroid membrane in the same direction in its whole extent ; if the open- 
ing is not sufficiently large, prolong the incision into the contiguous cartilages or 
transversely. 

If expulsion should not immediately take place, introduce the double 
cannula (Fig. 333), which secures freedom of respiration and stops hemor- 
rhage ; the contracted muscles of the larynx may become relaxed, and the 



DISEASES OF THE LARYNX. 



829 



foreign body, set at liberty, be expelled. When the patient has recovered 
from the immediate effects of the operation, the cannula may be removed, 



Fig. 231. 



Fig. 232. 





Incision in laryngotomy. 



Position of patient in laryngotomy. 



and the larynx explored by means of a probe ; if the body is not detected, 
use a larger instrument, as an elastic catheter ; the laryngoscope may also be 
used, and if the foreign body is detected it may be extracted with curved 
forceps (Fig. 234). If not extracted, the patient may now be safely inverted 



Fig. 233. 



Fig. 234. 





Double tracheal tube, movable plate, silver. 



Laryngeal forceps. 



and the back struck repeated blows, which often dislodges smooth, rounded 
bodies, as shot, bullets, or pieces of money ; if these means all fail, the 
larynx must be fully exposed. 

T hyrotomy , incision of the thyroid cartilage, is not a difficult operation, and 
does not involve much risk. Place the patient in the position already given (Fig. 
232) ; make the incision through the cartilage perpendicularly upward from the 
opening in the crico-thyroid membrane previously made, and exactly in the middle 
line. Make the same search as before, and when the foreign body is removed bring 
the edges of the incision through the thyroid body together, and secure them by 
suture ; the laryngeal tube may be retained a few days, until all indications of local 
mischief have passed away. 

Burns and Scalds result from inhalation of flames, hot vapors, and 
attempts to swallow boiling liquids. Violent inflammation follows, with great 
pain in attempting to swallow, hoarseness, dyspnoea, and croupy symptoms, 
which gradually become extreme. In a fair proportion of cases little other 
treatment is required than a warm bed, the application of a hot sponge to 
the larynx, and the inhalation of warm, moist air. In more severe cases 
blisters or leeches are useful ; but if the symptoms rapidly progress and 
laryngeal spasm occurs, tracheotomy must be promptly performed, chloroform 
being given without fear. 

If there is immediate danger, proceed as follows : 



830 LOCAL DISEASES. 

The patient being anaesthetized or not, as may be deemed best, and firmly held, 
the shoulders elevated and the head extended, stand at his right side and place the 
fore finger of the left hand on the left side of the trachea, and the thumb on the 
right side, and make uniform, steady, deep pressure until the pulsation of both 
carotid arteries is felt ; now slightly approximate the finger and thumb until the 
trachea is firmly and securely held between them, and maintain this grasp until by 
repeated cuts in the median line the trachea is exposed ; the fore finger of the right 
hand should be used from time to time to determine the relation of parts ; when 
the trachea is exposed it may be opened at once, or seized by a sharp hook and 
held while it is opened ; make the opening by thrusting the point of the knife, the 
edge directed upward, into the tube, and carrying it upward to a sufficient extent. 

It is important to keep strictly in the median line, otherwise the cannula will 
stand away in the wound, and its extremity will be turned sharply against the 
membrane of the trachea, and will not only cause irritation, but will quickly 
become blocked with mucus. The point of the knife must certainly penetrate the 
mucous membrane, which, if swollen, may be pushed before it; but it must not be 
thrust too deeply, lest it penetrate the posterior wall and the oesophagus ; if the 
first opening is too small, it must be enlarged. 

If there is not immediate danger, proceed as follows : 

The patient being in position, carefully examine the region and determine the 
precise point of opening the tube ; make a straight incision exactly in the median 
line, extending from just above the cricoid cartilage, nearly as low as the sternum ; 
if the patient has a short, fat neck, make the first incision long enough ; the subcu- 
taneous fat and connective tissue being divided, the sterno-hyoid muscles are ex- 
posed, divided by a faint line, along which make an incision dividing the fascia ; 
continue the dissection cautiously through the fascia and connective tissue, layer 
by layer, the separated tissues being held aside, and every bleeding vessel secured 
until the trachea is exposed and opened. 

In every case, however apparently hopeless it may have become, the operation 
should be completed and the tube introduced, even though the patient has ceased 
to breathe before this can be accomplished ; the most persevering effort should be 
made to effect resuscitation by aid of artificial respiration, and by sucking out the 
blood that may have entered the trachea, for recovery has repeatedly been effected 
in cases apparently the most hopeless. 

The last stage of the operation varies with the object in view ; if it has 
been undertaken on account of the presence of a foreign body, the edges 
of the opening should be held well apart by means of blunt hooks or 
dressing-forceps, or silk or wire ligatures may be passed through each edge 
of the wound, and tied behind the neck of the patient ; if the body is 

comparatively large and im- 
Fig. 235. pacted in the upper part of 

the trachea, it is better to 
introduce a cannula into the 
tracheal wound, and wait until 
all spasm has had time to sub- 
side ; if, however, the body is 
comparatively small and is sit- 
uated in the lower part of the 
trachea, it is better to lose no 
time in attempting to extract 
it by means of forceps, lest it 
Broad-beaked forceps. find its way into the bronchi. 

The forceps best adapted to 
seize the body has a peculiar curve (Fig. 235), with broad beaks. Or it 
may have a pliable shaft which can be bent at any curve, and will retain 
that position (Fig. 236) ; when introduced it may be closed and then acts as 
a probe ; if the foreign body is felt, the blades can be gently protruded, and 




PSEUBO-JIEMBBANOUS CBOUP. 831 

when they enclose the body be closed upon it, and removal is readily effected. 
If the operation is undertaken for disease, a cannula should be selected which 

Fig. 236. 




Flexible forceps. 

can be worn with comfort, and which will be least liable to obstruction. It 
should always be double, and so curved as not to press upon the anterior wall 
of the trachea. 



CHAPTER IV. 

PSEUDO-MEMBEANOUS CEOUP (TEUE CEOUP). 

The term pseudo-membranous laryngitis or laryngo-tracheitis, or true 
croup, is applied to a common and fatal disease, the essential anatomical 
character of which is inflammation of the larynx, or larnyx and trachea, with 
the formation of a pseudo-membrane upon its surface. It occurs most fre- 
quently between the ages of two and twelve years, but infancy after the age 
of six months and early manhood are not exempt from it. 

Etiology. — Wherever diphtheria or pseudo-diphtheria prevails as an 
endemic or epidemic it is well known that a large majority of the cases of 
membranous croup are local manifestations of one or the other of these 
diseases or of the two combined (mixed infection). Whenever the laryngeal 
or laryngotracheal inflammation reaches a certain grade of severity it may 
be attended by the exudation of fibrin and the formation of a pseudo- 
membrane ; but such a result more frequently occurs in the inflammation 
caused by diphtheria or pseudo-diphtheria than in that produced by other 
agencies. 

The percentage of cases of diphtheria and pseudo-diphtheria in which the 
larynx becomes implicated and croup occurs varies in different epidemics and 
in different seasons and localities. In epidemics of a mild type the cases 
appear to be fewer in which the larynx and trachea are involved than in 
epidemics of a severe form. In New York the percentage is large. From 
December 1, 1875, to July, 1878, I preserved records of all the cases of 
diphtheritic diseases which came under my notice. The number was 104, 
and in 25 of these, or about 1 in 4, croup occurred, producing the usual 
obstructive symptoms and constituting the chief source of danger. During 
the two and a half years embraced in these statistics the disease was usually 
severe. Subsequently amelioration occurred in the type, and the proportion 
of croup cases has not been so large. Since the differentiation of diphtheria 
and pseudo-diphtheria has been recent, the term " diphtheria " in the follow- 
ing statistics necessarily embraces also cases of pseudo-diphtheria. 

So commonly is membranous croup, when occurring in a locality where 
diphtheria is endemic or epidemic, a local manifestation of diphtheria that 
physicians in such localities come to regard most cases of this disease of the 
larynx as produced by the diphtheritic poison. In New York physicians 



832 



LOCAL DISEASES. 



scarcely recognize any other form of membranous croup. It is well, there- 
fore, briefly to recall the evidences that croup in a certain proportion of 
cases results from other causes than diphtheria. The occurrence of croup 
in localities where diphtheria is unknown of course indicates the operation 
of some other agency than the diphtheritic poison. Thus, in 1842, before 
diphtheria was established in this country, Dr. John Ware of Boston pub- 
lished his well-known paper on croup, and in 74 of the 75 cases embraced in 
his statistics the membranous exudation was present upon the faucial surface. 
The statistics relating to the introduction of diphtheria into New York City 
and the recorded death-statistics of this city were annually published, and 
each year more or fewer deaths from croup were reported. The first death 
from diphtheria in this century within the city limits, certified by a physician, 
was that of a German woman at 638 Hudson street on February 15, 1852. 
Two other fatal cases occurred in 1857, and since then the deaths from croup 
and diphtheria have been as presented in the following table : 



Year. 

1858 . 

1859 . 

1860 - 

1861 . 

1862 . 

1863 . 
1864. 

1865 . 

1866 . 



Croup. Diphtheria. 



.478 
. 622 
. 599 
.460 
. 685 



754 

449 



o 

53 
422 
453 
594 
981 
781 
534 
435 



Year. 

1867 

1868 

1869 

1870 

1871 

1872 

1873 

1874 

1875 



Croup. Diphtheria. 



338 


251 


342 


276 


483 


328 


421 


308 


466 


238 


675 


446 


732 


1151 


594 


1665 


758 


2329 



Since 1875 weekly bulletins have been issued instead of the annual reports. 

Thus, in the first years after the introduction of diphtheria the deaths 
assigned to croup so greatly outnumbered those of diphtheria, as in 1858, 
when 5 died of diphtheria and 478 of croup, that it is evident that most 
of the cases of croup in those years were attributable to other causes than 
diphtheria. Since, as we have stated, any inflammation of the surface of the 
larynx and trachea, if sufficiently intense, may produce a pseudo-membrane, 
croup may occur as a primary disease and as a complication of various mal- 
adies. From the fact that croup was prevalent and fatal in the first half of 
the present century, before the occurrence of diphtheria, it is evident that 
we must look for some other cause for it. I cannot resist the conviction that 
it's cause prior to 1850 was pseudo-diphtheria ; in other words, the presence 
and action of the streptococcus and staphylococcus. According to my obser- 
vations in New York City, the chief causes of croup, arranged in the order 
of frequency, would be about as follows : Diphtheria, pseudo-diphtheria, or 
the inflammation caused by streptococci and staphylococci, " taking cold," 
measles, pertussis, scarlatina, typhoid fever, irritating inhalations. Did 
space permit, other cases might be cited showing the causal relation between 
the other diseases mentioned above and croup. 

Scarlatina is so often complicated by diphtheria that there seems to be a 
close affinity between the two diseases. It is a very common observation in 
New York City that scarlet fever continues two or three days in its usual 
form, when the symptoms become suddenly aggravated and the aspect of the 
disease more severe. On inspecting the fauces a pseudo-membrane is dis- 
covered covering this region, and it probably appears also upon the nasal 
surface. Although severe scarlatinous inflammation may cause a fibrinous 
exudation, yet that diphtheria or pseudo-diphtheria has supervened upon 
scarlet fever in a considerable proportion of cases which have the above 
history has been demonstrated by the microscope. In a few instances in my 
practice the fact that scarlet fever was complicated by true diphtheria, and 



PSEUD0-2IE1IBRAX0US CROUP. 833 

the scarlatinous inflammations first in order were intensified by the presence 
and influence of the diphtheritic virus, was shown by the occurrence of diph- 
theria without scarlet fever in other members of the family. 

In accordance with the above law we may assume that a child who has 
larvngo-tracheitis, so common from taking cold and manifested by cough and 
hoarseness, is more prone to have diphtheritic croup than is one whose air- 
passages are in their normal state when diphtheria commences. A supposed 
error of diagnosis is often made by physicians, always to their discredit, who 
diagnosticate catarrhal laryngitis, but find after two or three days that their 
patients really have membranous croup. A considerable number of such 
instances have come to my notice, always with the ill-will of families toward 
their physicians. Now, it cannot be doubted that in many of these cases the 
physicians have been right in their first diagnosis, and membranous croup 
supervened on the catarrhal inflammation. 

Anatomical Characters. — It is important to acquaint ourselves with 
the anatomical characters of croup, especially with the nature of the pseudo- 
membrane, that we may know what measures to employ in order to remove it 
and prevent, so far as possible, the laryngeal stenosis from which so many 
perish. The surface of the larynx, trachea, and in severe cases that of the 
bronchial tubes, is hyperasrnic and swollen, and the inflammatory action 
involves more or less the submucous connective tissue, causing infiltration 
or oedema. The relation of the exudation to the mucous surface varies 
according to the kind of epithelium present. Where the epithelium is of 
the flat or squamous variety the fibrinous exudation from the blood-vessels is 
poured out around the epithelial cells, which perish. If the inflammation 
extend more deeply, the underlying connective tissue is also embraced in the 
coagulation and perishes. Prof. Ziegler of Tubingen, who has made repeated 
microscopic examinations of the pseudo-membrane, says : " It sometimes hap- 
pens that the dead epithelial cells become saturated with the exuded liquid 
and then pass into a peculiar condition of rigidity akin to coagulation. The 
seat of this change appears to the naked eye as a dull, raised, grayish patch 
surrounded by red and swollen mucous membrane. The exudation is rich in 
albumen, and the transformed cells take on the appearance of a kind of 
coarse meshwork almost or altogether devoid of nuclei." This is superficial 
inflammation, and Prof. Ziegler next describes deep or parenchymatous 
inflammation, as follows : " It is characterized by the coagulation not merely 
of the epithelium, but also of the underlying connective tissue. The affected 
patch is swollen and assumes a whitish or grayish tint, the discoloration 
extending through the epithelium to the connective-tissue structures. The 
epithelium in some cases is lost altogether, and then the diphtheritic patch 

consists of dead connective tissue only The dead tissue is separated 

from the living by a zone of cellular inflammation. Fibrinous filaments are 
seen here and there through the mass. The lymphatics in the neighborhood 
contain coagula and leucocytes." 

Squamous epithelium covers the nostrils, buccal cavity, fauces, and 
larynx upon and above the superior vocal cord, with the exception of its 
anterior aspect. The pseudo-membrane, therefore, upon all these surfaces 
lined with this form of epithelium consists of the exudate from the blood 
which surrounds and permeates the epithelium or epithelium and subjacent 
connective tissue. These two distinct elements, that poured out from the 
blood-vessels, and the normal tissue of the mucous surface now dead, incor- 
porated in one mass, constitute the pseudo-membrane. Its intimate relation 
with the surrounding living tissue is such that we cannot detach it without 
lacerating the latter and causing hemorrhage. 

The anterior aspect of the larynx from the middle of the epiglottis down- 
53 



834 LOCAL DLSEASES. 

ward, all that part of the larynx below the superior vocal cord, the entire 
trachea, and the bronchial tubes, are lined by columnar epithelium. When- 
ever this variety of epithelium is present the exudate from the blood does 
not become incorporated with the mucous membrane, but escapes to the sur- 
face and coagulates in a layer over it. It is, therefore, loosely adherent to 
the underlying tissues, being attached to it by some fibrinous threads, and when 
it is peeled off the hyperaemic and swollen mucous membrane is seen under- 
neath in its entirety, unless, as is commonly the case, a considerable part of 
its epithelium has been shed and been expectorated. The loose attachment 
of the pseudo-membrane in the trachea and bronchial tubes is of the greatest 
significance in its relation to intubation and tracheotomy. 

The epithelial cells embraced in the pseudo-membrane undergo a change. 
Cornil and Ranvier say : " Wagner admits the fibrinous degeneration of the 

cells We have verified the description given by Wagner, but we 

would conclude that the cells are filled with a material which approaches 
mucin rather than fibrin." At the same time a fibrinous exudation occurs, 
binding together the cells. In the first week the pseudo-membrane forms 
more rapidly, and is usually thicker and more extended, producing dyspnoea 
more quickly than when it forms in the declining stage of the disease. If 
the membrane be detached by the forcible coughing of the patient, it is 
usually quickly reproduced, unless the diphtheria be in its advanced stage 
and abating. If the croup continue from four to six days, the pseudo-mem- 
brane begins to soften from commencing decomposition and to disintegrate. 
The minute fibres which attach it to the membrane give way, and in favor- 
able cases by the effort of coughing or vomiting it is thrown off. Separation 
is aided by the muco-pus which collects underneath. 

Symptoms. — Whenever croup is a local manifestation of another disease, 
such general or constitutional symptoms are present as commonly pertain to 
this disease, such as fever, anorexia, thirst, and progressive loss of flesh and 
strength. The temperature in the commencement in croup from this cause 
is often higher than at an advanced period, unless some complication occur, 
as pneumonia, which increases the heat of the system. The temperature is 
not, however, in the beginning ordinarily above 103° or 104°. Most patients 
also have those inflammations which commonly attend croup — i. e. pharyngi- 
tis and more or less coryza, but they are relatively unimportant in compari- 
son with the croup, for, unlike the croup, they do not in themselves involve 
immediate danger to life. 

Croup commonly begins gradually and insidiously, revealed at first to the 
physician by hoarseness or huskiness of the voice and a hoarse or harsh cough. 
Both voice and cough are feeble, lacking the fulness and sonorousness present 
in spasmodic laryngitis. In grave cases approaching a fatal termination the 
voice becomes more and more indistinct, and finally is suppressed. The 
cough also, which in the beginning of the croup was strong and expulsive, 
becomes feeble and ineffectual, and less frequent as the fatal result draws 
near. 

The amount of sputum varies considerably in different cases. If the 
inflammation extend no farther downward than the trachea, it is scanty, but 
if there be coexisting bronchitis, it is more abundant, consisting of muco-pus 
with occasional flakes of pseudo-membrane. By vomiting a larger quantity 
is expelled than by the cough. Occasionally masses of pseudo-membrane of 
considerable size are expectorated, even moulds of some part of the respira- 
tory passage, always with great temporary relief to the patient. A pseudo- 
membrane of considerable thickness and extent obstructs the expectoration 
of muco-pus, which, collecting in the lower part of the trachea and in the 
bronchial tubes, greatly increases the dyspnoea. The respiration is somewhat 



PSEUB0-ME3TBRAX0US CROUP. 835 

more frequent than in health, bnt it is not notably increased except when 
bronchitis or broncho-pneumonia is present. At an advanced stage, when 
stupor supervenes from non-oxygenation of the blood, the respiration may be 
slower than in health. 

Croup in its commencement and in the active period of diphtheria without 
treatment almost never remains stationary or abates. Little by little, or often 
quite rapidly, the laryngeal stenosis increases, and soon the patient begins to 
experience the want of air. He becomes restless, has an anxious expression 
of the face, seeks change of position, reaching out his arms to the nurse or 
mother to obtain relief. In some patients only a few hours elapse, and in 
others a day or more of gradual increase in the obstruction, when it becomes 
evident that death must soon occur unless relief be afforded. In this stage 
the post-clavicular, infraclavicular, suprasternal, and inframammary regions 
are depressed during inspiration, and the larynx is drawn with each inspira- 
tory act toward the sternum. While there is constant suffering, there are also 
occasionally most distressing attacks of dyspnoea, attended by an increase in 
the lividity of the features and extremities, which now have an habitual dusky 
palor. Sometimes these attacks are perhaps due to the doubling of a de- 
tached end of the pseudo-membrane on itself, or perhaps to a movement of 
the muco-pus by which bronchial tubes are occluded. With the ear applied 
over the larynx or upper part of the sternum, a loud rhonchus is heard both 
on inspiration and expiration, produced by the passage of the air over the 
obstruction, and obscuring to a great extent other sounds. Moist bronchial 
rales are also common. 

Those who recover from membranous croup without intubation or trache- 
otomy and by the use of inhalations — and thus far they are a minority — 
usually improve gradually, the obstruction diminishing by the softening 
and detaching of portions of the pseudo-membrane. After the detach- 
ment of the pseudo-membrane several days elapse before the thickening 
and infiltration of the mucous membrane disappear and the epithelial cells 
are restored. 

Diagnosis. — Catarrhal laryngitis with an unusual amount of thickening 
and infiltration of the mucous membrane and of the underlying connective 
tissue, so as to produce stenosis and obstruct respiration, may be mistaken for 
pseudo-membranous laryngitis. In the New York Foundling Asylum two 
children have at different times died with the symptoms of membranous 
laryngitis, and the obstruction was found to be due entirely to the thicken- 
ing and infiltration of the mucous and submucous tissues of the larynx by 
newly-formed corpuscular elements. Of course, death from catarrhal laryn- 
gitis is rare, but that this disease may produce such an amount of laryngeal 
stenosis as to cause even fatal dyspnoea, like that from the presence of pseudo- 
membrane, these two cases show. In most instances the diagnosis of mem- 
branous laryngitis from catarrhal laryngitis is easy by the presence of patches 
of pseudo-membrane on the fauces or by the history of the case, which evi- 
dently points to diphtheria as the cause. In the case alluded to above a child 
in my practice died with the symptoms of acute laryngeal stenosis, without 
any pseudo-membrane upon visible parts and with only a moderate phar- 
yngitis. This case, which might have passed as one of catarrhal laryngitis 
accompanied by an unusual amount of cellular and serous infiltration, as there 
was no known diphtheria in the vicinity, was really due to diphtheria, and 
was a local manifestation of that disease, for immediately after the death of 
the patient the two nurses had unequivocal symptoms of diphtheria. The 
difficulty in using the laryngoscope in young children is such when their 
fauces are swollen that it has not heretofore afforded much aid in the differ- 
ential diagnosis of the various forms of acute laryngeal stenosis, at least 



836 LOCAL DISEASES. 

when employed by the general practitioner. By microscopic examination 
the character of the croup can be ascertained as stated elsewhere. 

Prognosis. — In New York City, during the fifteen years ending with 
1878, the percentage of recoveries was very small, both under medicinal 
treatment and tracheotomy. During this long period, surgeons, not saving 
more than 3 to 5 per cent, of their cases by tracheotomy, performed this 
operation reluctantly. But since 1878 the percentage of deaths after 
tracheotomy has been reduced, and still further reduced by intubation. The 
mortality from croup is greater the younger the patients, for the younger 
the child the less the diameter of the air-passages and the more quickly 
laryngeal stenosis results. The younger the child, also, the more difficult is 
the use of the proper remedies, and the less the time for their use before 
fatal dyspnoea occurs. The result also largely depends upon whether the 
physician is summoned at the beginning of croup and appropriate remedies 
are early and persistently employed. In many instances the friends do not 
take alarm and the physician is not summoned till the disease is well under 
headway, and there is not the requisite time for efficient treatment. Ob- 
viously, also, croup, beyond all other diseases, requires faithful and intelligent 
nurses, for without the co-operation of such nurses night and day in the care 
of the patient the most judicious measures are often inefficient. 

Treatment. — Preventive. — In attending a case of inflammation of the 
upper air-passages the physician should notice at each visit whether the 
patient have any hoarseness or other signs indicating implication of the 
larynx, since if the danger be recognized at its inception it may perchance be 
averted. Ineffectual as inhalations may be for fully-declared croup, expe- 
rience fully justifies the belief that they are sufficient in a large propor- 
tion of cases to relieve that degree of laryngitis which is indicated by 
simple hoarseness, and which if it continue might eventuate in serious 
obstructive disease. If the physician observe such symptoms, he should 
immediately recommend that the air in the apartment be kept moist by the 
croup-kettle or pans of hot water, rendered alkaline by lime-water or sodium 
bicarbonate. The efficiency of this treatment is increased by employing a 
tent. I prefer, however, in most instances, to employ the steam-atomizer 
either with or without the croup-kettle. It should throw a heavy and con- 
tinuous spray as long as the premonitory symptoms of croup continue. It 
obviates the necessity of heating the apartment, which in hot weather is very 
uncomfortable. 

It is proper, in this connection, to consider which is the most efficient and 
the best agent for inhalation in croup. Have we an agent that can be safely 
used, which will prevent, when inhaled, the formation of the pseudo-mem- 
brane, or which will dissolve it when it has already formed ? The agents 
which have been most employed for this purpose are lime-water, lactic acid, 
pepsin, and trypsin. 

In selecting the one that is safest and most efficient the important fact 
should be borne in mind that anything which irritates, so as to increase the 
inflammation of the mucous surface, is injurious. Whatever intensifies the 
inflammation evidently augments the thickening and infiltration of the mucous 
membrane and increases the area as well as thickness of the pseudo-mem- 
brane. It is therefore harmful instead of beneficial. The teachings of Bre- 
tonneau and Trousseau did immense harm in the fact that they brought into 
use agents far too irritating to the sensitive mucous surface. Since the 
pressing danger in croup arises from the obstruction produced by the pseudo- 
membrane and by the thickening and infiltration of the mucous membrane 
underneath, that agent is indicated, if it can be found, which loosens and 
dissolves the pseudo-membrane, and at the same time tends to diminish, or 



BSEUBO-MBMBBAXOUS CBOUP. 837 

at least does not increase, the inflammation of the underlying tissues by its 
irritating action. Alkalies exert a solvent action on fibrin and mucin, and 
as the pseudo-membrane consists of the exudate from the blood largely fibrin- 
ous, and of epithelium and connective tissue which have undergone degenera- 
tion into a substance resembling fibrin (Wagner) or perhaps mucin (Cornil 
and Eanvier). their employment seems to rest on a sound therapeutic basis. 
Lime-water slightly turbid, but not so turbid as to clog the point of the 
steam-atomizer, with its alkalinity increased by the addition of an unirritat- 
ing alkali, as sodium bicarbonate, may be used almost continuously by inhala- 
tion. Dr. E. M. Moore 1 of Rochester recommends insufflation of sodium 
bicarbonate as an active solvent of the pseudo-membrane. It possesses this 
advantage — that it is but slightly irritating, so that it can be used in sub- 
stance or with but little dilution. For this reason it should be preferred to 
lime-water, which is in more common use. 

Recently I have employed in the steam-atomizer the following formula, 
with o;ood results: 



Trypsin, 


3ij; 


Sodii bicarbonat., 


3*j; 


Aqua; calcis, 


Oj. — Misce. 



Trypsin may be advantageously used with this liquid, but trypsin in powder 
is very likely to clog the atomizer. The liquid trypsin, as prepared by Fair- 
child, should therefore be employed with the lime-water. The following for- 
mula may also be used in the hand atomizer : 

Trypsin, 3J ; 

Sodii bicarbonat. , gr. xx ; 

Aquae destillat., ^ij. — Misce. 

In some instances insufflation of the following powder, as stated in our 
remarks on diphtheria, has been useful as a solvent of pseudo-membrane in 
the air-passages : 

R. Papoid, ) 

Trypsin, >- da. ^ss ; 

Sodii bicarbonat., J 
Sulphur sublimat., £j. 

For insufflation. 

By the persistent and timely use of such inhalations as soon as hoarse- 
ness appears croup can be often prevented. But we all know how fre- 
quently, notwithstanding our best endeavors, croup occurring in the first 
week of diphtheria grows hourly worse. In these acute and rapid cases 
inhalations of the best agents which physicians have hitherto used act too 
slowly to prevent the growth of the pseudo-membrane, and in a few hours it 
becomes painfully evident that something more must be done or the life of 
the child is lost. In those many cases in which diphtheria is ushered in with 
croupous symptoms, and in which within a few hours laryngeal stenosis 
begins to occur, the experienced physician sees at a glance, often at his first 
visit, that inhalations, however faithfully employed, will be inadequate, and 
that suffocation, the most painful of all modes of death, will be inevitable 
unless other and energetic measures are used. 

On the other hand, in the milder forms of croup, in which the exudation 
has but moderate thickness and forms slowly, inhalations are of the greatest 
service, and aided by internal remedies they not infrequently arrest the dis- 
ease and save life. 

Calomel has long been used in the treatment of croup, and has done 
1 Transactions of the N. Y. Medical Association, 1885. 



838 LOCAL DISEASES. 

much harm in this as well as many other diseases. But, properly employed, 
it is one of the most efficient and useful remedies in croup, though the nurse 
and attendants incur the risk of severe and prolonged salivation. Calomel 
has long been employed in the treatment of croup in small and repeated 
doses, so as to keep up a daily purgation with an increase of the weakness. 
This effect has been pernicious, and it is believed has increased the mortality. 

The following method can be recommended from ample experience with 
it in Brooklyn, where it originated, and in New York, as probably the most 
effectual of the medicinal remedies to arrest the formation of the pseudo- 
membrane and aid in its detachment. A tent about five feet in height is 
erected over the bed in which the child lies, and the sublimation of 10 to 15 
grains of calomel is produced upon a tin plate over an alcohol lamp alongside 
the bed, and the fumes are received within the tent. The vapor is very pun- 
gent and irritating, and under a closed tent cannot be used without danger 
of salivation longer than twenty minutes, and oftener than three or four 
hours. In the New York Foundling Asylum, although this treatment has 
apparently saved the lives of foundlings having croup, the adults outside the 
tent were so severely salivated in a succession of cases that this remedy is no 
longer used in this institution. A physician of New York was so severely 
salivated by holding his head under the tent some hours, though his patient 
lived, that he was an invalid for some months afterward. The children, so 
far as I am aware, have not suffered from the deleterious effects of this medi- 
cine, but if it be employed the adults should make use of precautionary 
measures for their own safety. 

Emetics. — These have been largely used in all forms of croup, and in 
catarrhal or spasmodic croup they usually produce some relief. Formerly, 
emetics were much employed in the treatment of membranous croup, but 
now that diphtheria has spread throughout the country, and most cases of 
this form of croup occur in patients suffering from diphtheritic blood-poison- 
ing, depressing emetics, as ipecacuanha and antimony, have fallen into disuse. 
In my practice a child of ten years with severe diphtheria and with com- 
mencing croupy symptoms sank rapidly and died between two of my visits 
from exhaustion produced by a single large dose of ipecacuanha administered 
by anxious parents without my advice. 

An emetic may give partial relief to the dyspnoea in certain cases, since it 
assists in expelling the muco-pus which blocks up the tubes below the pseudo- 
membrane, and sometimes portions of pseudo-membrane, which are easily 
detached. But although there may be occasional advantages from an emetic, 
they are in most instances more than counterbalanced by the disadvantages, 
especially the prostration which results. If an emetic be employed, one 
should be selected which acts promptly with but little depression, and as a 
rule it should only be used at the commencement of croup. 

Surgical Treatment. — Although the best possible treatment by inhala- 
tions and internal medication be early employed and without intermission, 
yet it is the common experience in all countries that such treatment is in a 
large proportion of cases inadequate, and that many perish from suffocation 
unless relieved by surgical interference. We have stated above that if 
croup occur at the commencement of diphtheria, when the exudative process 
is active and the pseudo-membranes form rapidly and abundantly, death is 
the common result if the medicinal treatment only be employed. But if 
the inflammation be less intense or subacute, as in the second week in diph- 
theria, so that there is more time for the action of medicines and inhalations, 
and if, as is sometimes the case, the stenosis appears to be at a standstill, 
without any marked suffering from want of air, resort to surgical measures 
may be judiciously postponed. 



INTUBATION. 839 

The indications for surgical interference are a gradual increase of the 
stenosis and consequent dyspnoea, notwithstanding the constant and judicious 
use of remedial agents, and a manifest suffering from want of air, as shown 
by restlessness of the child and the expression of suffering in his features, 
with or without lividity of the surface. We adults may have some faint 
conception of the suffering which children with acute laryngeal stenosis 
undergo when we hare severe nasal catarrh and attempt to breathe with the 
mouth closed ; and the paramount duty of the physician to relieve suffer- 
ing should prompt a resort to other measures when medicines prove inade- 
quate, even if we leave out of account the important object of saving life. 
When, therefore, membranous croup is found to be progressive after having 
been observed and properly treated from six to twenty-four hours, and the 
child begins to suffer from want of air, the propriety of surgical measures 
should be considered. 



CHAPTER Y 



INTUBATION. 



The most important improvement made in recent years in the treatment 
of croup is intubation, for which the profession is indebted entirely to the 
genius and perseverance of Dr. Joseph O'Dwyer. Intubation is destined in 
the future to prevent an immense amount of suffering in the various forms 
of laryngeal stenosis. It has rescued, and will rescue, multitudes of chil- 
dren from a most painful death by suffocation. It is an operation of remark- 
able simplicity, quickly performed, without the use of anaesthetics and with- 
out pain to the patient. In this respect it contrasts strikingly with laryn- 
gotomy or tracheotomy, which is a painful and bloody operation, and which, 
for its proper performance, requires more or less delay. Those who have 
witnessed the slow suffocation of children in membranous croup and catarrhal 
croup when accompanied by cedema and infiltration can best appreciate the 
value of intubation. 

In 1858, Bouchut published a paper on the treatment of croup by intu- 
bation of the larynx. He employed a straight cylindrical tube nearly an 
inch long. The tube was introduced by means of a male catheter open at its 
two ends. Intubation excited some attention and discussion at the time in 
the Parisian capital, and M. Gross related a case of its successful employment. 
But, performed with such rude instruments, it met, as might be expected, 
with strong opposition from the first by such men as Barthez and Trousseau, 
who were bringing forward tracheotomy, and it soon fell into disuse and was 
forgotten. It was reserved for American surgery to achieve the honor of its 
successful employment. Dr. O'Dwyer, wholly ignorant of the previous his- 
tory of intubation, after many measurements of the larynx of the cadaver, 
many discouragements, and many modifications in the tubes to facilitate their 
introduction and retention, has so improved them that the objection to their 
use strongly urged by Trousseau thirty years ago, that they caused ulcera- 
tion, is inapplicable to the tubes now in use. Dr. O'Dwyer has kindly con- 
tributed the following paper descriptive of this operation : 

Intubation. 

By Joseph O' Dwyer, M. D. 

In the following pages I will confine myself to the practical details of this 
operation as applicable to those forms of stenosis of the larynx that occur 



840 LOCAL DISEASES. 

almost exclusively in children. The reader is referred to the appropriate sec- 
tions of this book for information in regard to the diagnosis, medical treat- 
ment, etc. of croup and kindred diseases. 

A very serious impediment to the success of intubation, and one for which 
there is no remedy, arises from the large number of grossly-imperfect instru- 
ments that are constantly being made and sold as the latest improvements. 
I will therefore first endeavor to point out some of the grosser defects referred 
to, in order that every one who uses these tubes may be able to distinguish 
the good from the bad. 

The most common defect, and at the same time the one attended with the 
most serious consequences, is apparently so insignificant that it is often over- 
looked by the manufacturers, even after their attention has been repeatedly 
called to it. It results from filing the metal so thin on the anterior surface 
of the distal extremity as to produce a cutting edge at this point. It should 
be remembered that this part of the tube is not only in contact with the ante- 
rior wall of the trachea, but that it also moves up and down over a space of 
about half an inch during every act of swallowing. This position is pro- 
duced by the backward pressure of the base of the tongue, which pushes the 
epiglottis and the upper extremity of the tube before it with considerable 
force, tilting the lower extremity forward, which glides upward as the larynx 
is raised and the trachea stretched, to fall back to what may be called its res- 
piratory position as soon as the act of swallowing is completed. 

If sharp, or even in the slightest degree rough, at the point indicated, a 
proportionate degree of injury will be inflicted on the mucous membrane, 
sometimes amounting to a deep ulcer, which adds to the danger of systemic 
infection and gives rise to painful deglutition and bloody expectoration. 

In the perfect tube the metal on the anterior surface is left quite thick 
and smoothly rounded off like the runner of a sled, so that it will glide up 
and down over the tissues without injuring them. As the distal extremity 
of the tube seldom impinges on the posterior wall of the trachea, and never 
touches the sides, the metal at these points should be comparatively thin, to 
avoid increasing the size, but the whole should form a perfectly smooth probe- 
point when the obturator is in position. If the obturator do not project far 
enough beyond the end of the tube or if it fit imperfectly, the sharp edges 
will be left unprotected, which will injure the tissues while passing through 
the narrowed glottis. 

The metal is also left thick on the anterior surface of the upper extrem- 
ity, in order to prevent the formation of a cutting edge under the epiglottis. 
The head or shoulder of the tube which rests in the vestibule of the larynx, 
and which is compressed by the action of the constrictor muscles in every 
act of swallowing, should be absolutely free from any roughness or projecting 
angles or edges. This portion of the tube, about a quarter of an inch in 
length, has a backward curve to carry it away from the base of the epiglottis, 
where a perfectly straight tube would be liable to produce ulceration. 

Another very common defect is the imperfect fitting of the obturator, 
which allows the tube to wabble when attached to the introducer, and causes 
it to slip off if the operator fail to place it in the larynx on the first attempt. 
The instrument-makers find it very difficult to overcome this defect, owing to 
the joint in the shank of the obturator and the backward curve that exists in 
the upper portion of the tube. 

If properly made, the tube when attached to the introducer and ready 
for use should be as free from motion as if constructed of one piece. 

I have also noticed in many of the sets of instruments otherwise perfect 
that the lines indicating the years on the scales do not correspond to the 
length of the tubes, which renders it difficult for a beginner to select the 



IXTUJBATIOK 



841 



proper size. By observing the following rule the scale can be dispensed 
with : The smallest size is suitable for the first year of life, the second for 
the second year, the third size for from two to four years, and the others for 
two years each. 

A set of intubation instruments suitable for children up to the age 
of puberty consists of six tubes, an introducer (1) and extractor (3), a 
mouth-gag (2), and a scale of years (4) ; 6, introducer and tube ; 7, a large 

Fig. 237. 




Intubation instruments. 



round tube used for the expulsion of membrane. Each tube is supplied with 
a separate obturator, one end of which screws on to the introducer, while 
the other extends sufficiently beyond the distal extremity of the tube to 
convert the whole into a probe-point. The numbers on the scale represent 
years, and indicate approximately the ages for which the corresponding tubes 
are suitable. For example, the smallest size when applied to the scale, in- 
cluding the head or shoulder, will reach the line marked 1, and is suitable 



842 LOCAL DISEASES. 

for the first year of life, but may be used up to fifteen or eighteen months if 
the child is small for its age. 

The next size, which reaches the line marked 2, is intended for children 
between one and two years, but may be used up to three years, the only 
objection being that it is liable to be coughed out. The third size, marked 
3-4 on the scale, should be used between the ages of two and four years ; 
and so on. 

The largest tube in the set may be used in the early years of adolescence 
by having a string attached, but is of no use in the adult larynx, as it would 
either be expelled immediately or pass through into the trachea. 

When the proper tube for the age is coughed out, there is always room 
for the next larger size. In one case, of an infant aged twenty months, in 
which the two-year-old tube was twice expelled, I was obliged to insert the 
3—4 size. 

Indications for Intubation. — As the indications for this operation are the 
same as for tracheotomy, the reader is referred to the proper section of this 
work for information on this subject. 

Method of Operating. — A tube of proper size for the age is first selected, 
and strong silk or linen thread passed through the eyelet intended for this 
purpose. In case the tube is placed in the oesophagus instead of the larynx, 
it quickly passes into the stomach, drawing the string with it, unless the 
latter be held. To guard against this accident, therefore, the thread should 
be left long enough to reach the stomach and still protrude from the mouth. 

The obturator is then screwed tightly to the introducer and passed into 
the tube when it is ready for use. The antero-posterior or long diameter of 
the tube should then be in a line with the handle of the introducer. If the 
obturator be found to turn too far to bring it in this position, which usually 
occurs after having been used for some time, a washer of writing-paper of 
one or more thicknesses can be added. 

It is always advisable to push the tube off once or twice before inserting 
it, to be certain that it works easily. The person who holds the child should 
be seated on a solid chair with low back, and the patient placed on the lap 
with its head resting on the left shoulder of the nurse to avoid interference 
with the gag. The hands may either be held or secured by the sides by 
passing a towel or napkin around the body, and retained in that position until 
the tube is inserted and the string removed. Failure to pay particular atten- 
tion to this precaution is often the cause of much annoyance to the operator, 
for if the child gets its hands free for an instant, it seizes the thread and 
removes the tube. Fastening the hands in front of the chest or thick gar- 
ments in the same location are objectionable, as they render it difficult to 
depress the handle of the introducer sufficiently to carry the tube over the 
dorsum of the tongue. 

The gag should be inserted in the left angle of the mouth, well back, 
between or behind the teeth if practicable, and opened as widely as possible 
without using too much force. In children who have not at least one double 
tooth on the left side the gag should not be used, as it slides forward on the 
gums, and, besides being in the way, is likely to injure the incisor teeth. 
There is little difficulty in keeping the mouth sufficiently open with the 
finger, and no danger of being bitten if it be kept well to the patient's right. 
The necessity of using force is obviated by allowing the child to compress 
the finger for a few seconds until the jaws relax before carrying back into 
the pharynx. The Denhard gag, which is shown in the cut, holds better 
than the one originally devised by the author, and seldom slips if properly 
placed. 

An assistant, standing behind, holds the head firmly by placing one hand 



INTUBATION. 



843 



on either side. and. if without experience, should be requested not to touch 
the gag. The operator, either standing or sitting in front of the patient, the 
former position being preferable, holds the introducer lightly between the 
thumb and lingers of the right hand, with the thumb resting just behind the 
button that serves to detach the tube, and the index finger in front of the 
trigger-support underneath. Held in this position, it is impossible to use 
force enough to make a false passage, while if firmly grasped in the hand the 
beginner is very liable to lacerate the tissues. 




Intubation of the larynx. 

The index finger of the left hand is now quickly passed well down in the 
pharynx or beginning of the oesophagus, and then brought forward in the 
median line, raising and fixing the epiglottis, while the tube is guided beside 
the finger into the larynx. 

If any difficulty be experienced in feeling the epiglottis, it is better to 
seek the cavity of the larynx, a cul-de-sac into which the tip of the finger 
readily enters, and which cannot be mistaken for anything else. Once in this 
cavity, the epiglottis must be in front of the finger, and the latter is then 
raised and carried to the patient's right in order to leave room for the tube 
to pass beside it. As the larynx contracts when touched, thereby diminish- 
ing its aperture, it is necessary to keep the distal extremity of the tube close 
to the finger, or even directing it a little obliquely to the right in order to get 
inside the left aryepiglottic fold. This is particularly important in very young 
children, in whom the tip of the finger completely covers the larynx. 

In the beginning of the operation the handle of the introducer is held 
close to the patient's chest, and rapidly raised as the lower end of the tube 
passes behind the epiglottis ; otherwise, it slips over the larynx into the 
oesophagus. 

When the tube is inserted, it is slipped off by pressing forward the button 
on the upper surface of the handle with the thumb, while counter-pressure 



844 LOCAL DISEASES. 

is made by the index finger underneath. In removing the obturator the tube 
must be held down by placing the finger either on the side or posterior por- 
tion of the shoulder. The tube should be carried well down before being- 
detached, otherwise it is liable to become occluded with false membrane when 
subsequently pushed home with the finger. When the tube is in place the 
gag is removed, but the string is allowed to remain for about ten minutes, 
or until it is ascertained with certainty that the dyspnoea is relieved and that 
no loose membrane is present in the lower portion of the trachea. 

In removing the thread the finger must be reinserted to hold the tube 
down, but the reinsertion of the gag is rarely necessary for this purpose. 
The extraction of the tube is much the more difficult operation, and at the 
same time the more dangerous as far as injury to the larynx is concerned. 
The patient is held in the same position as for insertion, and the extractor is 
guided along beside the finger, which is first brought in contact with the head 
of the tube, and then carried to the right in order to uncover the aperture and 
leave room for the instrument to enter beside it. 

Before inserting the extractor it should be ascertained with certainty that 
the tube is still in the larynx. This can be determined by the tubal charac- 
ter of the cough, which is characteristic, the difficulty of swallowing, and, 
lastly, by the sense of touch if necessary. 

Difficulties of the Operation. — Few who have not practised intubation 
recognize the fact that it is a difficult operation to perform, and that it is 
difficult simply because it must be done quickly and at the same time gently. 
Sufficient dexterity to fulfil both of these requirements can only be acquired 
by a great deal of practice, and if this be gained on the living subject it must 
be at the expense of a great deal of unnecessary suffering and the sacrifice 
of many lives as well. It is the sense of touch alone that is to be relied 
upon, and that requires to be educated ; consequently, the accomplished 
laryngologist who has only educated his sense of sight is no more competent 
to perform the operation than one who has never seen the larynx in its nor- 
mal position. 

The operator has so many movements to make, involving both hands, in 
such a brief space of time that unless he have had sufficient practice to make 
some of these movements to a certain extent automatic, he cannot operate 
with safety to his patient nor with credit to himself. The epiglottis must be 
found, raised, and held in this position as the tube is glided down in contact 
with the finger, otherwise the operator does not know where it is ; it has to 
be slipped off at the right moment, and held down while the obturator is 
being removed ; and to be safe all these movements must be completed in less 
than ten seconds. 

Intubation should therefore never be attempted, except in case of emer- 
gency, without some preliminary practice, either on the cadaver, on one of the 
smaller animals, or on a larynx removed from the body. Let the beginner 
who has never performed either operation choose tracheotomy rather than 
intubation, as being the safer, because in the former he can see what he is 
doing and his patient can breathe during the progress of the operation. Prac- 
tice on a child's cadaver is within the reach of comparatively few, but it can 
be done on that of one of the smaller animals, such as a cat or dog, with prac- 
tically the same result — viz. education of the sense of touch and automatism 
in some of the movements. 

In addition to a moderate amount of this kind of practice, every young 
operator should keep a small larynx in preservative fluid on which he can 
continue to practise at frequent intervals by placing it upright in the neck 
of a bottle or other receptacle in the same relative position which it occupies 
in the body. 



IXTUBATION. 845 

There is no doubt that dexterity in the use of these instruments can be 
acquired in this manner ; and this is particularly important in extracting the 
tube, which is so difficult to do without injuring the larynx. 

The difficulty sometimes experienced in intubating older children who 
offer resistance is to a great extent obviated by placing their legs between 
the knees of the person acting as nurse and holding them firmly in that 
position. 

Accidents and Dangers of Intubation. — The most serious of the avoidable 
accidents attending this operation is asphyxia, from holding the finger too 
long in the throat. It should be remembered that when intubation is called 
for the patient is getting very little air, and can afford to dispense with this 
little only for a very short time without danger to life. After the insertion 
of the gag an expert can, as a rule, place a tube in the larynx in five seconds 
or less, and without any shock worth considering. The novice, on the con- 
trary, having so many other things to occupy his attention, is very liable 
to forget how long his finger has been in the throat, and that during this 
time respiration is practically suspended. A fatal issue under these circum- 
stances is almost invariably attributed to pushing down membrane, which 
is not a common accident, and has never proved immediately fatal in my 
hands. 

There is seldom any danger from repeated failures to intubate, provided 
the finger be not retained in the pharynx longer than ten seconds at a time, 
and the child be given a chance to get its breath between the attempts. 

It is well for the beginner always to have another physician present, 
who while holding the head will watch the patient closely and be prepared 
to give some prearranged signal to stop when he thinks there is danger of 
asphyxia. 

The ventricles of the larynx seldom offer any obstruction to the entrance 
of the tube, as they are usually obliterated by the swollen mucous mem- 
brane and covered over by the fibrinous deposit in croup ; but this should be 
remembered if any resistance be encountered, as it does not require much 
force to make, a false passage at these points. 

Pushing down a mass of pseudo-membrane before the tube is the most 
serious of the unavoidable accidents attending intubation in croup. In the 
majority of cases the offending membrane is expelled on the withdrawal of 
the tube, if the latter be inserted quickly and as quickly removed when the 
respiration is found to be suspended ; and even if none be expelled, the 
patient is in no worse condition than he was in before the operation. 

I have devised and tried various instruments for the removal of pseudo- 
membrane from the trachea, but I have found short cylindrical tubes of large 
calibre the most successful. Being short, they do not accumulate masses of 
membrane before them, and, while overcoming the obstruction in the glottis, 
afford relief to the dyspnoea where the long tubes fail. They are only 
intended for temporary use, as, owing to their large size, extensive ulcera- 
tion would result if long retained. The string should be left attached and 
secured behind the ear, by which the tube can be removed at the end of four 
or five hours whether any false membrane be expelled or not. The amount 
of dilatation from the pressure accomplished in this time will usually secure 
several hours of relief from dyspnoea and give ample time for the physician 
to reach the patient and reintubate, if necessary. Should the offending 
membrane still be retained, it is better to use the same tube on the recur- 
rence of dyspnoea than to again run the risk of producing apnoea by insert- 
ing the long one ; otherwise the latter is preferable. 

These tubes (Fig. 237, 7) have no retaining swell, the size alone being 
sufficient to retain them. The metal of which they are constructed is made 



846 LOCAL DISEASES. 

very thin, in order to have as large a lumen as possible, and they can also be 
used to facilitate the expulsion of foreign bodies from the lower air-passages. 
Under these circumstances they can be left in position for a much longer 
time without danger from pressure, because the mucous membrane of the 
larynx is in the normal condition. 

A separate introducer with long curve is necessary for these tubes in 
order to carry them well through the subglottic division of the larynx before 
removing the obturator. 

Danger of Asphyxia from Loose Membrane below the Tube. — The ex- 
istence of loose membrane below the tube — that is, in the lower portion of 
the trachea — usually gives rise to the following signs : A napping sound with 
the respiratory movements, a hoarse or croupy character of the cough, and 
obstructed expiration, especially when forced, as in the act of coughing. In 
some cases there is no difficulty while the breathing is quiet, but the egress 
of air is completely cut off with the first attempt at coughing. The vis d 
tergo thus developed is often sufficient to cause the expulsion of both tube 
and pseudo-membrane, but this does not always occur, and precautions should 
be taken to avoid the danger of sudden death from this cause. 

The safest plan is to leave a string attached, by which any one who is 
present can remove the tube in case of threatened asphyxia. Should this 
not be practicable, owing to the age or from other causes, a smaller tube than 
that indicated by the scale of years should be used, which would be more 
likely to be coughed out in the event of its sudden occlusion. Either of 
these methods should be resorted to if the symptoms of loose membrane in 
the lower part of the trachea, absent at the time of operation, subsequently 
show themselves. 

Premature expulsion of the tube seldom occurs when the proper size has 
been used, and is rarely attended with danger, provided the patient be within 
easy reach. 

Dangers of Extraction. — Cases have been reported in which the tubes as 
now made, with large heads, have passed through into the trachea. This 
accident can only occur when the tissues of the larynx, cartilages included, 
have been extensively lacerated by the extractor by passing it down on the 
outside of the tube and withdrawing it with force. This danger has been 
minimized to a great extent by the addition of a regulating screw to the 
extractor, which prevents the blades from opening any wider than is necessary 
to hold the tube firmly. 

No force is necessary to remove a tube from the larynx, and if any 
appreciable resistance be encountered, it is pretty certain that the instrument 
is caught in the tissues. Severe hemorrhage often results from a very moder- 
ate laceration produced in this manner. 

When the Tube should be Removed. — In a large number of recoveries 
following intubation in croup the average time the tube was retained 
amounted to five days. The longest time in my own practice was twenty- 
nine days. The older the child, as a rule, the sooner it can be dispensed 
with. In very young children, when progressing favorably or if the patient 
be not within easy reach, it is better to leave it in position for seven or eight 
days. The frequent removal of the tube, unless specially indicated by a 
recurrence of the dyspnoea or for other cause, is bad practice, principally 
because of the irritation produced on each occasion. In protracted cases, in 
which the dyspnoea returns soon after the second or third removal at regular 
intervals of four or five days, it is safer to leave it in position continuously 
for two or three weeks, unless some special indication for its removal arises 
in the interim. If the tube be properly constructed and well plated, it will 
do no harm when retained for this length of time. 



INTUBATION. 847 

Management after Intubation. — One of the greatest advantages of intuba- 
tion over tracheotomy is the fact that no skilled nursing is required after the 
operation. The most important part of the after-treatment consists in getting 
the patient to take a sufficient amount of nourishment. The difficulty here- 
tofore experienced in this matter has been greatly reduced by the method 
suggested by Dr. W. E. Casselberry of Chicago. It consists in feeding while 
the patient's head is lower than the body. By this means advantage is taken 
of gravitation, thus allowing any fluid that may have entered the tube to 
escape without the act of coughing. The little patient soon learns this, and 
ceases to object to the uncomfortable position. For very young children at 
least the best position is lying on the back across the lap, with the head 
hanging well below the level of the body, and feeding from a spoon or bottle. 
Older children may be allowed to assume any position they wish, provided 
the head be lower than the chest. 

Fig. 239. 






Feeding in the upright position should always be by spoon, at least for 
the first two or three days, and the patient be given time and encouraged to 
cough between the acts of swallowing. By this means any danger from the 
entrance of food is obviated. Nourishment in the solid and semi-solid forms 
— which are swallowed better than liquids — should be given the preference 
when children can be induced to take them. 

Rectal feeding is rarely necessary, but when resorted to the food should 
be given in small quantities — not over two ounces — and at intervals of three 
or four hours. 

No food or medicine should be given for two or three hours after intuba- 
tion, unless the presence of the tube fail to excite sufficient cough to get rid 
of accumulated secretions. It is principally by the act of coughing that the 
tube is kept clear, and, if this does not occur voluntarily, it may be excited by 



848 LOCAL DISEASES. 

giving some irritating substance, such as carbonate of ammonia, brandy strong 
or slightly diluted, etc. If this plan be adopted and the air of the room be 
kept well saturated with warm vapor, it will rarely be found necessary to 
remove a tube for the purpose of cleaning it. The presence of a tube in the 
larynx does not contraindicate the use of an emetic, which is sometimes 
necessary when the bronchi are loaded with secretions. 



CHAPTEE VI. 

TRACHEOTOMY. 

Prior to the employment of intubation by O'Dwyer tracheotomy was one 
of the most important operations in surgery. Properly performed and at the 
proper time, with judicious after-treatment, it has rescued many children 
from a most painful death. The details of this operation are given in surgi- 
cal treatises, but some general remarks relating to it will not be inappropriate 
here. 

Lange says that the operator should have three assistants, at least one 
of them a physician. One should administer chloroform, one use the 
sponge, and the third, a physician, should be ready to assist in handing 
instruments, ligating vessels, etc. The operation is simple and devoid of 
danger, or difficult and dangerous, according to circumstances. The younger 
the child, the greater the danger, other things being equal. The greatest 
difficulty and risk attending tracheotomy is in fleshy infants with thick and 
short necks, and in patients who have extreme dyspnoea and are nearly mori- 
bund, so that the operator is compelled to hurry in the operation through 
fear that death will occur before the trachea is opened. The operator should 
have time for slow and cautious dissection, that he may avoid wounding 
vessels and other important parts. 

Tracheotomy may be performed above, through, or below the thyroid isthmus ; 
the latter place gives more room for the cannula and is to be preferred. Provide 
a firm table covered with several folds of blankets ; bichloride solution 1 : 1000 ; 
iodoform and iodoform gauze ; carbolized sponges ; hot and cold water. The fol- 
lowing instruments are useful : A scalpel ; two blunt hooks with bulbous ends ; 
catch forceps ; two tenacula for holding the wound apart ; two tenacula with hooks 
at right angles with the shaft to transfix and hold the trachea when it is opened ; 
two grooved directors ; artery forceps ; forceps with fine teeth ; the oculist's spring 
hook to open the wound ; tracheotomy-tube with two cylinders ; pigeon's quills. 

Place the patient on the table ; elevate the shoulders with a pillow, and support 
the neck with a firm compress or covered block of wood, so as to throw the head 
well backward. Wrap the child in a sheet, enclosing the arms and legs to control 
its movements. One assistant gives the chloroform or holds the head ; a second 
takes charge of the instruments, and a third of the sponges. Standing on the right 
side, the surgeon gently compresses the trachea between the thumb and finger of 
the left hand and defines the median line. Commencing at the cricoid cartilage, he 
makes an incision through the skin within a third of an inch of the sternum. With 
hooks the wound is kept open, and he proceeds to cut the tissues down to the 
trachea, or with the blunt hooks inserted into them in the median line he may, by 
traction in the axis of the trachea, tear through these tissues without hemorrhage. 
The wound should be frequently wet by sponges moistened in the bichloride solu- 
tion. Care should be taken not to make lateral traction, in order not to draw the 
trachea to one side. All bleeding vessels should be secured before the trachea is 
opened. The dissection may be made on a director introduced under the tissues in 
the median line, or the operator may seize the tissues on one side with toothed 



TRACHEOTOMY. 849 

forceps and an assistant do the same on the other side, and, making the parts tense, 
the tissues are divided in the median line. 

The isthmus of the thyroid will be met with, and must be drawn upward or 
downward according as the opening is made above or below this body. If it is 
found necessary for any reason to divide it, ligatures should first be passed around 
it on either side and tightened to prevent hemorrhage Avhen the incision is made 
through it. The trachea is recognized by its white appearance and its rings. When 
exposed the connective tissue should be removed from the anterior surface where the 
opening is to be made so as to prevent emphysema. In opening, steady the trachea 
with the thumb and fingers, or insert a hook into the upper part and make traction 
upward in the median line sufficiently strong to steady the tube. The point of the 
bistoury or narrow-bladed knife should be introduced between two rings of the 
trachea, the cutting edge upward, and three or four rin'gs be divided. Air escapes 
with a loud hissing sound, and mucus with blood, perhaps membrane, is ex- 
pelled. The wound should be drawn apart with hooks or toothed forceps, and 
the operator should be prepared to seize any protruding membrane which may be 
loose. The first inspirations may be difficult, but very soon the mucus and shreds 
are dislodged and the breathing becomes more tranquil. If there are evidences 
of the presence of the loosened exudation, curved forceps may be introduced 
cautiously and search made. It is frequently useful to have the patient inhale 
hot vapor, and sponges moistened with hot water may be held with forceps over 
the opening. Everything being in readiness, the double cannula is gently inserted, 
and a tape fastened to the rings is tied behind the neck. 

Much of the success in tracheotomy for croup and diphtheria depends on 
the efficiency of the treatment after the operation and subsequent manifesta- 
tions are completed. The patient should be put to bed in a room at a tem- 
perature of not less than 70° F., for a certain amount of chilliness usually 
ensues, proportionate to the amount of hemorrhage during the operation and 
to the intensity of dyspnoea before it ; the external opening should be covered 
with a fold of woollen gauze or scarf, straddled upon a tape or strip of plaster 
applied above the wound, which protects the trachea from dust and warms 
the air a little as it is inhaled ; the risk of pneumonia is thereby lessened, 
and the liability diminished to clogging of the tube by the accumulation of 
desiccated crusts and fragments of false membrane. The atmosphere of the 
room should be kept moist as well as warm by means of steam escaping in 
the immediate vicinity of the patient, or, if this means be lacking, flat sec- 
tions of sponge wrung out of hot water should be kept over the tube ; if the 
reaction from the chill be tardy, warm aromatic drinks should be administered, 
and flying; sinapisms should be applied to the trunk and limbs, which will 
cause restlessness to subside and sleep ensue. Sleep, indeed, often comes on 
before the dressings are completed, and occasionally on the operating table 
as soon as the cannula has been inserted. The membrane will probably be 
coughed through the unobstructed orifice. 

The removal of the cannula, especially during the first twenty-four hours, 
necessitates a skilled hand for its reintroduction. When it cannot be replaced, 
or its presence prevents expulsion of obstructing products, some other method 
of keeping the orifice open must be employed, and the dilating retractor, if 
retractors are employed, will be of great use ; hooks may be improvised from 
hair-pins, and may be held in position by tapes passed around the neck. 
Skilled judgment is necessary for the recognition of these important points 
and for their proper management ; an officious nurse may interfere unneces- 
sarily on the one hand and do injury on the other. The obstructed character 
of the respiration is a guide for interference: under all circumstances the 
condition of the inner cannula should be observed every two or three hours, 
to clear it of any viscid secretions that may have adhered to it ; these should 
be carefully examined in water, so as to detect membranes, which will float 
out in flat pieces, their amount indicating how the case is progressing. At 

54 



850 LOCAL DISEASES. 

the end of twenty-four hours or thereabouts the cannula, soiled as it is with 
blood and sputum, should be removed for -cleansing, and be replaced by a 
clean one ; it is best to do this by daylight, and with the child in the same 
position as when it was inserted ; this removal is followed by cough and dis- 
charge of morbid products ; the tube being removed, the parts are to be care- 
fully inspected and carefully cleansed. If everything has gone on well, the 
tube, if of silver, though soiled by mucus, pus, and blood, will not be tar- 
nished. If blackened, mortification is indicated at the corresponding point 
of the wound ; if the tissues are healthy, the parts will be normal in color 
and soft, and the edges of the wound will be everted. Sometimes the parts 
will be so pliable as to turn inward and occlude the tracheal incision ; then a 
dilator should be introduced to keep the wound open until a tube is inserted ; 
meanwhile, if indicated, search may be made for false membrane. The can- 
nula should be changed once a day, and the wound dressed if need be ; when 
air begins to pass by the natural passage, as tested by covering the external 
wound with the finger-tip, the tube may be left out for a few minutes after 
each dressing, to be replaced immediately should respiration become embar- 
rassed ; from day to day the tube may be dispensed with for increasing inter- 
vals, until it is finally put aside. One of the most favorable indications for 
this procedure is expectoration by the mouth. 

As the cannula exposes the patient to the risk of bronchitis and broncho- 
pneumonia, it should be removed at the earliest possible period ; to determine how 
necessary the instrument is, close the external opening from time to time and watch 
the effects ; it should not be withdrawn unless the patient can breathe for some 
hours with the orifice plugged. The wound usually closes rapidly after the cannula 
is removed. 

Foreign bodies passing through the larynx and trachea generally enter 
the right bronchus, owing to the peculiar anatomical arrangement at the 
bifurcation ; the symptoms produced and the obstruction to respiration 
depend upon whether the substance is fixed or movable, its size, nature, and 
precise position : if impacted in one of the bronchi, the entrance of air into 
the corresponding lung is more or less impeded, or the obstruction may be 
complete, with entire loss of respiratory murmur on the affected side. The 
body may not occupy the whole calibre of the bronchus, when the vesicular 
murmur will be diminished, or it may be lodged in one of the primary or 
secondary divisions, causing an entire absence of the murmur over a certain 
limited space ; natural resonance on percussion is usually preserved ; but as 
a rule the chest rises less, during inspiration, on the affected than on the 
sound side, and the respiration is puerile in the obstructed lung ; fixed pain 
referred to the upper part of the chest when the body is immovable, or con- 
stant pain with a sense of weight on one side, sometimes indicates the posi- 
tion of the foreign body ; the voice may be hoarse, the respiration wheezing, 
the cough aggravated by deep inspiration ; inflammation adds to these symp- 
toms a copious and offensive expectoration, paroxysms of fever, night-sweats, 
and exhaustion. When the symptoms indicate that the foreign body is in 
one of the bronchi, tracheotomy should be performed, and the opening should 
be of considerable extent and as low down as possible. The removal may 
sometimes be effected, if the foreign body is globular, by inversion of the 
patient and giving the posterior wall of the chest a blow, but care must be 
taken that the substance does not lodge in the larynx and cause suffocation. 
If it is not dislodged, it must be extracted by instruments : first explore with 
a long probe in order to learn the exact position of the body, then introduce 
suitably curved forceps and seize and remove it. 



BROXCHITIS. 851 

CHAPTER VII. 
BKONCHITIS. 

Inflammation of the bronchial tubes, or bronchitis, is probably the most 
frequent disease of early life. It is usually associated with more or less 
inflammation of the mucous membrane of the nostrils, larynx, and trachea. 
We designate the disease coryza, laryngitis, or bronchitis according as one or 
the other inflammation predominates. Sometimes bronchitis occurs with but 
slight inflammation elsewhere, and often the coryza and laryngitis abate 
while the bronchitis is still active. 

Bronchitis occurs both as a primary and secondary disease. The sec- 
ondary form is common in connection with measles, whooping cough, pneu- 
monia, and pulmonary phthisis, and it is not uncommon in remittent and 
continued fevers. Bronchitis is acute, subacute, or chronic, and according to 
its extent it is mild or severe. If the smallest bronchial tubes are involved, 
the inflammation is designated capillary bronchitis — a term not well chosen, 
but which is conveniently employed in a description of the malady. Bron- 
chitis is commonly bilateral, affecting the tubes on the two sides with about 
equal intensity. When due to tubercles or to pneumonia it is often unilateral, 
being confined to those tubes or nearly to those which lie in the tubercular 
or inflamed pulmonary tissue. 

Causes. — The causes of secondary bronchitis are obviously the diseases 
in connection with which it occurs. The cause of primary bronchitis is the 
same as that of simple acute laryngitis or coryza — namely, sudden change 
of temperature from warm to cold, exposure to currents of air, the practice 
of sending children without sufficient clothing from heated rooms into the 
open air. the throwing off" of bedclothes at night, etc. 

Anatomical Characters. — In the most common form of bronchitis the 
larger bronchial tubes only are affected. They are the seat of the inflamma- 
tion in most of those cases which are designated " colds " by families, and 
which are often treated without the aid of the physician. The lining mem- 
brane of the bronchial tubes presents the ordinary anatomical characters of 
mucous inflammations. It is reddened uniformly or in patches, intensely or 
in that milder degree known as arborescence, according to the severity of the 
inflammation. 

The secretion of the muciparous follicles is at first arrested and the sur- 
face of the membrane is dry. In the course of a day or two the secretory 
function is re-established, and the surface is covered with thin and transpa- 
rent mucus. A day or two later the secretion becomes thicker, consisting of 
mucus and pus. Mixed with these substances are epithelial cells, which are 
exfoliated in abundance from the inflamed surface. At the same time the 
mucous membrane becomes thickened and more or less softened. If the 
inflammation be severe, the vessels of the submucous connective tissue are 
also injected. 

Usually in about a week in the young child, in from one to two weeks in 
older children, the inflammation begins to abate. Gradually the inflamed 
membrane returns to its normal consistence, thickness, and vascularity, and 
with this return to the healthy state the muco-purulent secretion abates. 

In this, which is the simplest and most common form of bronchitis, there 
is no ulceration, and rarely any pseudo-membranous formation if the disease 
be idiopathic. Pseudo-membranous bronchitis is not unusual as an accom- 
paniment of pseudo-membranous laryngo-tracheitis. 



852 LOCAL DISEASES. 

Were bronchitis limited to the larger bronchial tubes, it would indeed be 
a simple affection, but, unfortunately, it has a tendency to extend downward. 
Commencing in the larger, it gradually invades the smaller tubes in a similar 
manner to the extension of erysipelas upon the skin. More rarely the inflam- 
mation commences simultaneously in the larger and smaller tubes. The grav- 
ity of bronchitis is proportionate to the degree of its extension downward. It 
may stop at any point in its progress, but if it reach the smaller tubes it is 
one of the most serious affections of early life. 

The mucous membrane of the minute tubes, those next to the air-cells, is 
delicate, with but little submucous connective tissue, and it frequently, at 
post-mortem examinations, does not present to the eye those distinct inflam- 
matory changes which are observed in tubes of larger diameter. It is some- 
times not notably thickened nor its vascularity much increased, even when 
there is reason to believe from the symptoms that it was the seat of active 
phlegmasia. As we pass from these minute tubes to those of larger calibre 
the inflammatory lesions become more distinct. The inflammation produces 
minute and abundant points of redness and the membrane is evidently thick- 
ened ; often it is rough or granular. 

The minute bronchial tubes are very small, especially under the age of 
three years, and, since in capillary bronchitis a large proportion of them are 
inflamed, the source of the danger is apparent. It is with difficulty that 
the patient with capillary bronchitis can by the effort of coughing free the 
tubes from the secretions which are constantly collecting in them. In 
weakly children under the age of two years expectoration is most difficult, 
and hence the great and increasing dyspnoea from which such patients suffer. 

In severe and unfavorable cases of bronchitis, which are chiefly those in 
which the small as well as large tubes are inflamed, the following anatomical 
changes commonly occur : The muco-purulent secretion, which is tenacious, 
collects more rapidly in the smaller tubes than it is expectorated by the child, 
whose strength begins to be exhausted. The accumulation of the secretion 
is chiefly in the tubes which lie in the posterior and inferior portions of the 
lung. As the obstruction from the muco-pus increases in these tubes, less 
and less air passes through them into the alveoli with which they communi- 
cate, while the quantity of air which passes through the unobstructed tubes 
into the anterior and superior portions of the lung is proportionately increased. 
The effect, as regards the state of the lung, is obvious. In cases having a 
fatal issue, and in which we are therefore able to inspect the lesions, we find 
that the lower and inferior portions of the organ, from which air was to a 
greater or less extent excluded, have a diminished crepitation ; that they lie 
a little below the general level, or that certain lobules do ; and that they pre- 
sent a congested appearance, for. while they contain too little air, they have 
an excess of blood. We shall also find that the upper and anterior parts of 
the organ, perhaps the entire upper lobe, contain more than the normal quan- 
tity of air, so as to rise above the general level. There is distention of the 
alveoli in these parts, so that they are probably visible to the naked eye, 
and may appear to be emphysematous ; but this is a state distinct from 
emphysema. It is merely an inflation of the alveoli to nearly their full 
capacity. 

Here and there in the portion of lung in which the inflation has been 
incomplete lobules may be observed which are entirely collapsed, having a 
dusky-red color and no crepitation ; while in other parts, if the bronchitis 
have continued some days, there are nodules of pneumonia. Often when 
the bronchitis is severe the inflammation, commencing in the bronchial 
tubes, extends to the lungs, usually to lobules in the lower lobes, constitut- 
ing broncho-pneumonia. The occurrence of pneumonia is announced by 



BBOSCHITIS. 853 

an aggravation of symptoms, and frequently by the expiratory moan. The 
incised surface of these portions of the lung to which the access of air has 
been prevented, whether they are collapsed fully or partially or not, has a 
reddish color from congestion and is moist from serum and blood. On com- 
pressing the lung the muco-purulent secretion appears upon the surface in 
points, having escaped from the divided ends of the tubes. (For other facts 
relating to Atelectasis the reader is referred to the chapter in which this mal- 
ady is described.) 

Exceptionally, even when not accompanied by laryngeal croup, fibrinous 
exudation occurs in the bronchial tubes, forming a delicate film here and 
there, and readily detached from the surface underneath, while in rare 
instances it occurs as a firm and continuous membrane, forming a mould 
of the tubes, increasing greatly the dyspnoea, constituting a true bronchial 
croup. If the patient with severe bronchitis survive, the inflammation of 
the mucous membrane soon begins to abate. The tubes which have been 
the seat of the disease and the alveoli which have been secondarily involved 
may return to their normal state almost immediately ; but in other instances 
such anatomical changes occur in them, even when there is no pneumonia 
nor atelectasis, that full restoration to their normal state is necessarily some- 
what slow. AVhen the function of a lobule ceases, as it does when the tube 
leading to it is obstructed, not only hypersemia occurs, with or without col- 
lapse, as already stated, but its cells and nuclei, and perhaps other parts, 
begin to undergo fatty degeneration. These elements become granular, 
somewhat enlarged and opaque, and here and there mixed with them are 
other large cells filled with oil-globules. These are the compound granular 
cells of pathologists, and, occurring in this situation, are produced by meta- 
morphoses of the epithelial cells. They are epithelial cells which have pro- 
gressed more rapidly than others in fatty degeneration, having reached that 
stage of it which immediately precedes liquefaction. We often with the 
microscope observe not only these corpuscles, but their fragments as they are 
dissolving. 

Minute abscesses, usually directly under the pleura, have occasionally 
been observed at the autopsies of those who have recently had general bron- 
chitis, and pathologists are not agreed as to the mode in which they are pro- 
duced. Some of them, if not all, are evidently connected with the minute 
bronchial tubes, and the quantity of pus contained in each is not usually 
more than one or two drops. The most reasonable view of their causation is 
that they are produced in the terminal tubes where the mucus and pus col- 
lect. The pus acts as an irritant and causes inflammation, and the inflamma- 
tion increases the quantity of pus. The walls of the tube which is now the 
seat of an abscess are destroyed by ulceration, and probably also some of the 
contiguous air-cells. The little cavity is soon surrounded by a delicate mem- 
brane, the same in character, though less thick and firm, as that which con- 
stitutes the walls of larger abscesses. The pus presents the usual appear- 
ance of this liquid, or it may be tinged by the presence of blood-cells, or, 
again, it may be thick from partial absorption of the liquor puris, so as to 
resemble softened tubercle. 

The abscess is ordinarily located in the centre of a collapsed lobule. In 
certain cases it approaches the surface of the lungs, so as to produce circum- 
scribed pleurisy, with adhesion of the costal and visceral pleura. At the 
autopsy of such a case, on separating the adhesions and attempting insuffla- 
tion, the air passes through the aperture, so that the lung on that side can- 
not be inflated unless the aperture be closed. Occasionally pneumothorax 
results from opening of the abscess into the pleural cavity. 

In severe protracted bronchitis dilation of certain of the bronchial tubes 



854 LOCAL DISEASES. 

sometimes results. The alveoli in the upper lobes may also be distended 
beyond their physiological capacity, so as to produce emphysema, but, as we 
have stated above, their maximum distention within physiological limits 
must not be mistaken for emphysema. Emphysema in the upper lobes is 
common in feeble young children with relaxed and weakened tissues, occur- 
ring even without any severe disease of the respiratory organs. It may be 
vesicular or interstitial. If it be interstitial, the sacs of air often attain 
considerable size, lying as wedges between the alveoli or like little bladders 
upon the surface of the lung, where the entrance of air is least obstructed 
and greatest. 

Symptoms. — It is evident, from the description which has been given of 
the anatomical characters of bronchitis, that its symptoms vary greatly in 
severity in different patients. It usually commences with more or less 
coryza. The symptoms are headache, flushed face, elevation of temperature, 
acceleration and fulness of pulse. In the mildest cases these symptoms are 
scarcely appreciable. The child is observed to sneeze and have some deflux- 
ion from the nostrils, and this is followed by an occasional mild, almost pain- 
less cough, which declines in the course of a few days. The respiration and 
pulse are scarcely accelerated and the appetite is but slightly impaired. 
There may be a little fretfulness, but the child is not confined to his bed or 
room, and usually amuses himself with his playthings. Auscultation in 
these mild cases reveals coarse mucous rales in the larger bronchial tubes, 
while the smaller tubes are free from mucus. Sibilant and sonorous rales 
are also observed, especially in the commencement of the bronchitis, at which 
time the secretion of mucus is suppressed or scanty. The cough in the 
commencement is for the same reason dry. It becomes looser by the second 
or third day, the sputum consisting of frothy mucus, with the admixture 
of pus and epithelial cells. The pus becomes more abundant as the disease 
continues. Expectoration from the mouth does not usually occur till after 
the age of four or five years ; under this age the sputum is ordinarily 
swallowed. 

The mild form of bronchitis described above, that in which only the 
larger tubes are affected, is common in infancy and childhood, but bronchitis 
of a more severe type is also common, due to extension of the inflammation. 
It has already been stated that there is a tendency in bronchial inflam- 
mation to extend downward, and symptoms are proportionate in gravity 
to the degree of this extension. In severe bronchitis the pulse rises to 
120 or 130 per minute, and the respiration is in a corresponding degree 
accelerated. The cough is frequent and painful, the pain being referred to 
the sternum, and often there is a steady dull pain in this region. The face 
is flushed and indicative of suffering, the temperature is considerably ele- 
vated, and the appetite is greatly impaired or lost. There is frequently an 
exacerbation of symptoms in the latter part of the day. Depression of the 
inframammary region during inspiration and dilation of the alse nasi accom- 
pany grave attacks of the inflammation. 

Auscultation in severe bronchitis reveals the presence of rales in all parts 
of the chest, sibilant and sonorous sparingly, coarse mucous and subcrepitant 
more abundantly. 

General bronchitis or suffocative catarrh, the most dangerous form of this 
inflammation, is less frequent than bronchitis, which is limited to the larger 
tubes or to the larger tubes and those of medium size. It may commence 
quite abruptly, but ordinarily it results from the milder form of the disease. 
The symptoms at first are such as occur in the common form of bronchial 
inflammation, but, instead of abating or remaining stationary, they grad- 
ually increase in severity till suddenly marked dyspnoea supervenes. The 



BROXCHITIS. 855 

inflammation has now reached the minute tubes, and what promised to 
he an ordinary attack of bronchitis becomes one of great severity and 
danger. 

The respiration in severe bronchitis is short and hurried. Sixty to eighty 
inspirations per minute are not infrequent, while the pulse also is greatly 
accelerated, attaining as high a number as 140 to 160 or 180 beats per minute. 
The cough is frequent, and the sputum, which collects in abundance, is 
expectorated with difficulty. If expectorated so as to be examined, it is 
found to consist largely of frothy mucus with epithelial cells. After a few 
clays, if the patient live, it becomes more purulent. Sometimes, as in bron- 
chitis of the adult, streaks of blood appear upon the mucus. In the first 
days of severe acute bronchitis the temperature is considerably elevated, the 
face flushed, and the breathing oppressed. The patient is restless, moving 
from one part of the bed to another, seeking in vain for relief. The diges- 
tive function is impaired, as in all severe inflammations ; the tongue is moist 
and covered with a light fur ; the appetite is nearly or quite lost. The 
infant takes the breast with difficulty, frequently relinquishing it on account 
of the dyspnoea ; older children take no solid food in consequence of the ano- 
rexia and the dyspnoea, and even drinks are swallowed hastily and apparently 
without relish, since deglutition interferes with respiration. On auscultation 
in bronchitis of the minute tubes sibilant, and after a day or two subcrepi- 
tant. rales are observed in every part of the chest. Percussion elicits a 
good resonance unless the substance of the lung have become involved. As 
the disease approaches a fatal termination the pulse becomes greatly acceler- 
ated ; the respiration is also in a corresponding degree frequent and panting, 
the inspiration being accompanied by increased inframammary depression 
and dilation of the alae nasi. The face becomes pallid, the prolabia livid, and 
the tips of the fingers livid and cool. The mucus and pus, accumulating in 
the air-passages, increase more and more the obstruction to the entrance of 
air, and finally death occurs from apncea. The nursing infant usually ceases 
to nurse several hours before death, and a state of stupor commonly pre- 
cedes the fatal event, due to the accumulation of carbonic acid in the blood. 
In young infants, especially those under the age of six months, not only in 
bronchitis of the minute tubes, but in severe ordinary bronchitis, I have 
often observed toward the close of life intermission in the respiration. It 
occurs after every six or eight or ten respirations, and equals in duration the 
time occupied in perhaps half a dozen respiratory movements. It is there- 
fore an unfavorable prognostic sign, but some in whom it occurs recover by 
active stimulation. 

The duration of acute bronchitis varies according to the extent of the 
inflammation. In the mildest form the patient is convalescent after three or 
four days, and in severe cases that terminate favorably the disease begins 
ordinarily to decline by the close of the first week or in the second. The 
progress of bronchitis is somewhat more rapid in young children than in 
those of a more advanced age. When convalescence is fully established it 
is not unusual for the cough to continue three or four weeks, though grad- 
ually declining. It is loose and painless, and is scarcely regarded by the 
patient. 

Death sometimes occurs as early as the second or third day in severe gen- 
eral bronchitis. The younger the infant, with the same extent and intensity 
of inflammation, of course the sooner the fatal result. The ordinary dura- 
tion of fatal bronchitis is from six to eight days. If the patient pass beyond 
the tenth day, decline of the inflammation may be confidently expected, with 
recovery, unless there be a complication. 

Occasionally bronchitis becomes chronic, lasting several months before it 



856 LOCAL DISEASES. 

entirely ceases. The chronic form may result from mild as well as severe 
bronchitis. The acute fever and accelerated respiration which characterize 
the acute affection abate, and the general health is nearly or quite restored ; 
but an occasional cough continues, and the respiration is often audible, from 
the mucus which collects in the tubes or from thickening of the mucous 
membrane. Sometimes there is moderate fever, especially in the latter part 
of the day. On auscultation coarse mucous, with perhaps sibilant and sono- 
rous, rales are observed in the chest. 

There is great liability in chronic bronchitis to exacerbations. The dis- 
ease often seems to be abating and there is prospect of its speedy cure, when 
all the symptoms are intensified. The exacerbations are due to the fact that 
the bronchial surface, when it has been a considerable time inflamed, is very 
sensitive to the impression of cold. Even when the disease is entirely 
relieved, it is very liable to return by exposure to currents of air or changes 
of temperature. Chronic bronchitis occurs most frequently in the winter, 
spring, and autumn, when the weather is changeable, and is most intractable 
in these periods of the year. Many cases of chronic bronchitis are associated 
with dilation of the bronchial tubes or with emphysema. The general health 
in this form of bronchitis, when not depending on a tubercular deposit, ordi- 
narily remains good. Tubercular bronchitis, which is the result of a grave 
disease, is treated of in our remarks on Tuberculosis. It is attended with 
emaciation, and is obstinate on account of the nature of the primary affec- 
tion. It is due to the irritating effect of tubercular matter lying against the 
bronchial tubes. 

Diagnosis. — Bronchitis can ordinarily be diagnosticated by the character 
of the respiration and cough. The absence of hoarseness, stridulous inspira- 
tion, and croupy cough excludes laryngitis, and the absence of the expiratory 
moan and of the stitch-like pain on coughing, which characterize pneumonia 
and pleurisy, excludes these diseases. Accurate diagnosis, however, can be 
most readily made by percussion and auscultation. Examination of the chest 
enables us to state with positiveness not only the nature, but the extent, of 
the affection. If the inflammation be confined to the larger bronchial tubes, 
coarse rales are discovered in them, while finer mucous rales are absent. If 
the bronchitis be in the minute tubes, subcrepitant rales are discovered in 
them. Percussion gives clear resonance on both sides, except in those instances 
in which atelectasis or pneumonia has supervened. 

Prognosis. — Bronchitis limited to the larger bronchial tubes or to these 
and those of medium size terminates favorably in a large majority of cases. 
Occasionally, severe inflammation, not extending to the smaller tubes, proves 
fatal to young infants or those of feeble constitution. Bronchitis extending 
to the minute tubes is. on the other hand, a disease of great danger. It may 
be fatal at any period of childhood, but the younger and more feeble the 
patient the greater the liability to a fatal result. Under the age of one year 
it is one of the fatal diseases of early life. 

The prognosis in the commencement of all cases of bronchitis of average 
severity in the young child should be guarded, on account of the tendency 
of the inflammation to extend, as has been already stated in the preceding 
pages. After five or six days extension ceases, and if during that time no 
increase in the severity of symptoms occurs the prognosis is favorable. 
Signs which indicate an unfavorable result are increasing frequency of pulse 
and respiration, difficult and scanty expectoration, restlessness, a countenance 
expressive of suffering, and a progressively greater accumulation of mucus 
in the bronchial tubes, as determined by auscultation. Pallor and coldness 
of the face and extremities, lividity of the tips of the fingers, rapid and 
feeble pulse, drowsiness, diminution of cough, while the mucus and pus 



BEOXCHITIS. 857 

accumulate in the bronchial tubes, and, in young children, intermissions in 
the respiration, indicate the near approach of death. Cases may, however, 
recover by proper treatment, although the symptoms are most unfavorable. 

It is unnecessary to mention the favorable prognostic signs of bronchitis. 
This disease, when fully established, continues a certain number of days what- 
ever remedial measures are employed, and if the symptoms do not increase 
in severity during the first five or six days, a favorable result is highly prob- 
able. The prognosis in chronic bronchitis is ordinarily favorable, so far as 
life is concerned, provided that no emaciation occurs. If there be emaciation, 
the bronchitis may be due to tubercles in the bronchial glands or lungs, and 
of course the prognosis is less favorable. 

Treatment. — Bronchitis may be rendered much milder, and perhaps 
prevented, by an emetic employed in the first twelve or twenty-four hours 
in conjunction with a warm bath. The physician is not, however, ordinarily 
called sufficiently early to render this treatment effectual. 

Mild Bronchitis. — In mild bronchitis, the inflammation being limited to 
the larger tubes or to these and those of medium size, simple, soothing, 
expectorant, and laxative remedies are required. Mild counter-irritation may 
be produced by camphorated oil or the following : 

R. Olei caryophvlli, ^ij ; 

Olei camphorati, ^iv. 

For external use. 

And one of the following mixtures may be given : The late Dr. James Jack- 
son of Boston, in his letters to a young physician, writes of the treatment: 
" For young children I employ the following : Take of either almond or olive 
oil. of syrup of squills, of any agreeable syrup, and of mucilage of gum acacia 
equal parts, and mix them. Of this mixture a teaspoonful may be given 
to a child two years of age ; a little less if younger and increased if older, 
so as to double the dose to one in the sixth year. This may be given from 
three to six times in the twenty-four hours. Sometimes a little opiate must 
be added at night to appease the urgent cough." Another good medicine is 
the mistura glycyrrhizae composita, half a teaspoonful of which should be 
given every two hours to a child of three years and one teaspoonful to one 
of six years. The syrupus ipecacuanhas compositus of the French Pharma- 
copoeia, the centre cle la toux, consisting of ipecacuanha, senna, thyme, poppy, 
sulphate of magnesia, orange-flower water, wine, water, and sugar, being 
soothing and slightly laxative, is also a useful remedy. These cases also 
do well with simple mucilaginous drinks and confinement in a warm room. 
Bronchitis affecting the Medium-sized or Smallest Tubes. — In all cases 
of this disease in which the cough is dry and painful, or so frequent as to 
attract attention, the air of the room should be constantly moist. I prefer 
the use of the croup-kettle or steam-atomizer : 

R. Sodii bicarbonat, ^ij ; 

Aq. calcis, Oij. — Misce. 
Or, 

R. Terebinthinse, ,^j '■> 

Aquae purse, Oij. — Misce. 

In the New York Foundling Asylum the constant inhalation of air con- 
taining the turpentine vapor has been a favorable mode of treatment. It 
must be recollected that the muco-pus in the bronchial tubes contains numer- 
ous microbes, and they descend deeper during inspiration, and. if not expec- 
torated, by their irritating action tend to produce a downward extension of 



858 LOCAL DLSEASES. 

the inflammation. The inhalation of vapors like those mentioned above not 
only renders the muco-pus thinner and more easily expectorated, but to a 
certain extent also produces a disinfectant action. 

Local treatment applied to the chest in bronchitis is important, since, if 
properly made, it increases the comfort and obviously diminishes the intensity 
of the inflammation. Henoch, whose ample experience and sound judgment 
command attention, if not acceptance of his views, says of local treatment : 
" I strongly advise hydropathic applications to the chest from the neck to the 
umbilicus. A napkin or diaper is dipped in water at the temperature of the 
room, well wrung out, and then placed around the chest, without exercising 
any compression, so that the arms are free ; this is surrounded by a roll of 
batting and then covered by a layer of oil-silk or gutta-percha paper. When 
the fever is high these applications should be renewed at least every half 
hour ; later they may be kept on for one or even two hours, and this continued 
for several days and nights. I have occasionally continued it for a week, the 
cool water being changed to a temperature of 26° to 27° R " (90.5° to 92.8° 
Fahr.). 

The benefit derived from the cold-water application is, according to 
Henoch, threefold : First, the deep inspiration which the application of cold 
causes, thus expanding portions of the lungs which are liable to atelectasis ; 
secondly, " derivative irritation of the skin ;" and, thirdly, the production of 
moisture in the air surrounding the child, which he inhales. Deep inspira- 
tions are, in my opinion, caused to a greater extent by medicines which excite 
cough, as ammonia and warm applications certainly produce more derivation 
to the surface than cold. One benefit from the application of cold Henoch 
does not allude to, and that is the reduction of temperature. But I prefer 
for this purpose frequent sponging of the upper extremities and face with 
cold water, and perhaps its constant application to the head. I have observed 
marked relief from this use of cold water. 

For years, in my practice, the following external treatment has been 
employed with apparent benefit in nearly every case. For infants under the 
age of three months who have accelerated respiration and painful cough, 
indicating the need of external treatment, two poultices of ground flaxseed 
are prepared, covered by thin muslin and made so moist that they wet the 
hand in holding them. They are made as thin as the pasteboard cover of a 
book, and of such a size that, applied in front and behind, they cover the 
entire chest. Camphorated oil is smeared over their under surface three or 
four times daily, and over their exterior oil-silk is applied. For infants over 
the age of six months I prefer poultices of the following : 

R. Pulv. sinapis, %] ; 

Pulv. seminis lini, ^ xv j- 

The poultice, to give most relief, should be so wet as to cause constant moist- 
ure of the surface, and so irritating as to cause constant redness without 
necessitating its removal. Vesication should never be produced. Flannel 
wrung out of warm water made slightly irritating by mustard and covered 
by oil-silk also answers the purpose. External treatment should be employed 
in most instances so long as the respiration is hurried and cough painful. 
During the stage of convalescence, instead of the poultice, cotton wadding or 
batting around the chest increases the comfort and prevents taking cold. 
Derivation to the surface, early made and continued, tends to check the 
downward extension of bronchitis. Often improvement in the symptoms is 
observed, especially less dyspnoea and restlessness, immediately on the em- 
ployment of the local measures recommended above. 



JBEOXCHITIS. 859 

Internal Treatment. — Medicines are indicated which have a tendency to 
diminish the inflammation, to prevent its downward extension to the minute 
bronchial tubes, and to promote expectoration. The bowels should be kept 
open in all cases of bronchitis. For robust children at or over the age of 
six months the following prescription is useful in the commencement of the 
attack : 

R. Syr. ipecac, 

Spts. aether, nitr., da. gij ; 

Ol. ricini, ^iij ; 

Syr. bal. tolut., 5J. — Misce. 

Dose : Half a teaspoonful to one teaspoonful, every second hour, for the age of 
one to two years. 

But the medicinal agent which experience has shown to be the most use- 
ful in the bronchitis of children is one of the salts of ammonium. In the 
treatment of infantile bronchitis depression must be avoided. The cough 
should be strong and frequent, for the chief danger occurs from the accumu- 
lation of viscid mucus in the minute tubes, so as to obstruct the entrance of 
air into the alveoli, leading to atelectasis and causing the dyspnoea which is 
so painful and prominent a symptom in this disease. Ammonii carbonas or 
chloridum better than any other agent promotes expectoration by exciting 
cough and rendering the mucus less viscid, and it does not reduce the strength. 
When anxious parents ask me to prescribe something to relieve the cough, I 
reply that the more frequent the cough the better it is for the infant, since it 
aifords the means of freeing the tubes from the accumulating mucus. Gas- 
tric catarrh has been found in infants who have perished after repeated doses 
of the ammonium carbonate administered for pulmonary diseases. I there- 
fore prescribe it in water, and direct it to be administered in milk. In feeble 
cases and cases attended by dyspnoea the carbonate is preferable to the chlo- 
ride, since it is more stimulating and it promotes the cough by slightly irri- 
tating the fauces. The ammonii chloridum may in most instances be given 
with benefit from the commencement, both in mild and severe bronchitis, in 
infants under the age of one year, but in severe cases it is apparently less 
efficient than the carbonate. The following is a convenient formula for its 
employment : 

R. Ammonii chloridi, 3j ; 

Syr. bal. tolut., §ij. — Misce. 

Fifteen drops contain one grain, which is the dose at the age of three 
months. Five drops should be given at the age of one month, and thirty at 
the age of six months, in a little water. This expectorant should be given 
frequently, as every half hour or every hour in cases of severity. The urgent 
symptoms are relieved by free expectoration, which this medicine tends to 
produce. It should be given night and day, at the short intervals mentioned, 
until amelioration of symptoms occurs. The benefit from its use is most 
apparent under the age of eighteen months, or at the age when capillary 
bronchitis and atelectasis are most liable to occur. 

Medicines which exert a greater controlling effect on the action of the 
heart than those which we have mentioned are often required during the 
progress of severe " bronchitis." If the patient give evidence of declining 
strength while the pulse is unusually rapid and the temperature elevated, 
quinine given in moderate doses, as two grains every fourth hour to a child 
of two years, has seemed to me useful as a heart tonic. It may be employed 
in the following formula : 



860 LOCAL DISEASES. 

R. Quiniae sulphatis, gss ; 

Syr. yerbse santse comp., ^ij. — Misce. 

Give one teaspoonful every fourth hour. 

The tincture of digitalis in doses of one or two drops every second hour 
for infants between the ages of six months and two years is also useful 
as a heart tonic. In a case recently under treatment by Dr. Jacobi and 
myself the infant, aged twenty -three months, having a temperature varying 
from 102J° to 105J°, respiration 82 to 105, and pulse 165 and higher, took 
four drops of tincture of digitalis, besides the quinine and ammonii chloridum, 
three days, with apparently a good result from the digitalis. This remedy 
was afterward continued in two-drop doses, and the patient recovered. 

For robust children, with a strong and rapid pulse, with a temperature 
above 102°, the use of an antipyretic is indicated. Tincture of aconite, 
drop j, or phenacetin, gr. j, with citrate of caffein, gr. ss, may be given every 
third hour to an infant of one year. If the temperature fall to 102°, the 
antipyretic should in ordinary cases be discontinued, since it is in a measure 
depressing. Its use is seldom required longer than two or three days. For 
feeble children, or those who have atelectasis or pneumonia complicating the 
bronchitis, quinine is preferable to either of the above antipyretics. 

When and how to employ opiates to procure the needed rest in the bron- 
chitis of children should be carefully considered. We have stated that a 
frequent and strong cough is required in the infant in order to prevent clog- 
ging of the minute tubes with muco-pus and to prevent atelectasis. Still, 
some respite from the cough, if it be frequent, is required to prevent exhaus- 
tion. I prefer for young infants to give the opiate separately from the ex- 
pectorant, and only occasionally as they may need sleep. The following is a 
useful formula for an infant of six months if it be restless and without the 
proper amount of sleep : 

R. Liq. opii composit. (Squibb), gtt. x; 

Potass, bromidi, gj ; 

Syr. rubi idsei (raspberry), t ^j ; 

Aquae, ^iss. — Misce. 
Dose : One teaspoonful when needed. 

Eight drops of paregoric may be given in place of the above. Twice the 
dose of either of these opiates is sufficient at the age of twelve months. For 
older children Dover's powder — an eligible form of which is Squibb's liquid 
Dover's powder, the tinctura ipecacuanhas composita, one minim of which 
corresponds to one grain of the powder — is a useful remedy to procure sleep. 

During convalescence medicines should be administered less and less fre- 
quently or in smaller doses. Emetics in ordinary cases of bronchitis are not 
required, except in the commencement. In severe bronchitis, however, espe- 
cially when the smaller tubes are inflamed, they sometimes appear to be use- 
ful. The cases which may need their administration are those in which mucus 
and pus collect in the tubes more rapidly than they are expectorated, so as 
to give rise to urgent dyspnoea. An emetic administered under such circum- 
stances may give prompt and decided relief. The object to be gained is 
obviously very different from that in the commencement of bronchitis, and 
such agents should be employed as act promptly with little depression. 
Ipecacuanha is probably the best emetic for this purpose. 

Infants oppressed by the accumulation of mucus and pus may sometimes 
be relieved by tickling the fauces with the finger. This provokes vomiting, 
and the viscid mucus which collects at the entrance of the glottis is removed 
by the finger. 



ATELECTASIS. 861 

The diet should, as a rule, be nutritious through the entire disease ; but 
robust patients or those who have ordinary health, if over the age of two 
years and affected with primary bronchitis, are sufficiently nourished by light 
diet, chiefly farinaceous, in the first days of the attack, after which animal 
broths are proper. Whatever food is given in severe bronchitis must be in 
the form of drinks, since the appetite is lost and solid food is not taken, 
while the thirst is such that liquids are less likely to be refused. 

In primary bronchitis, if mild or of ordinary severity, alcoholic stimu- 
lants are not required. In secondary bronchitis they are often needed, and 
also in severe primary bronchitis if there be dyspncea with evidences of 
prostration. 



CHAPTER VIII. 

ATELECTASIS. 

In certain new-born infants the lungs do not undergo inflation or only a 
portion of the lobules is inflated — to wit, those in the upper lobes — while the 
remainder of the organ continues unchanged from the foetal state. This non- 
inflation of the lung is designated congenital atelectasis. It is apparently 
not due, unless in rare instances, to defective formation of the respiratory 
apparatus, for at the autopsies of cases which have ended fatally, as most 
cases do at an early period, insufflation is easy, there being no occlusion of 
the air-passages nor unusual adhesion of the walls of the alveoli to prevent 
the admission of air. Physicians have believed that in some instances they 
discovered the cause in an enlarged thymus gland, which compressed the 
lower part of the trachea, but this cause has not seemed to exist or was 
exceptional in cases which I have observed ; for although the thymus at 
birth is large, having nearly the size of an unexpanded lung, it has not 
seemed to me to be unduly enlarged in most atelectatic cases which I have 
examined after death. 

The ordinary proximate cause of atelectasis neonatorum is feebleness of 
inspiration, whether due to general debility, as in infants born prematurely, 
or weakened by placental hemorrhage in the last months of foetal life, or, as 
is frequently the case, to injury of the brain and consequent impairment of 
the function of the pneumogastrics during birth. I have more fully treated 
of this form of atelectasis in the chapters which relate to the maladies inci- 
dental to the birth of the child, and to these the reader is referred. 

Acquired atelectasis, or collapse of lung, is less extensive than con- 
genital atelectasis, being confined to a portion of a lobe and often to only a 
few lobules. It occurs chiefly during the period of infancy and in feeble 
children. It is a common malady in foundling asylums in wasted infants 
who perish before the close of the first year. I have frequently at the 
autopsies of such infants observed it along the thin inferior margins of the 
lower lobes and in the tongue-like prolongation of the left upper lobe. In 
this class of cases catarrh of the bronchial tubes appears to have little or no 
agency in causing the collapse. The cause is found in the impaired functional 
activity of the lungs. In the state of debility the heart beats feebly and 
the stream of blood from it to the lungs is small and slow, so that the inspira- 
tion of a small amount of air suffices for its decarbonization. The inspira- 
tions also are seen to be feeble, causing little expansion of the walls of the 



862 LOCAL DISEASES. 

thorax. Consequently, the entire lung is imperfectly inflated, as is seen in 
fatal cases, but the distant thin portions of the organ are least expanded. 
These, receiving little or no air, soon begin to contract from the presence of 
the elastic tissue, and collapse or atelectasis ensues. 

This has been the most common form of atelectasis in cases of this malady 
which I have observed in foundling asylums, and it probably occurred in the 
manner which I have described. 

Another case of acquired atelectasis to which all writers allude is bron- 
chial catarrh, which, commencing in the larger tubes, extends downward into 
those of smallest size. By the swelling of the mucous membrane and the 
accumulation of viscid muco-pus, which cannot be expectorated, certain of 
these tubules become occluded, so that the inspired air is shut off from the 
alveoli situated beyond them. Occlusions are obviously most likely to occur 
in the bronchitis of feeble infants whose cough has little expulsive force, 
so that debility is also a factor in the production of this form of atelectasis. 
The portion of lung withdrawn from the respiratory function soon collapses, 
the air which it contained being probably in part expired, but chiefly absorbed. 

Atelectasis is not, however, so important or frequent a complication of 
bronchitis as was formerly supposed, for catarrhal pneumonitis due to exten- 
sion of the inflammation from the bronchioles into the lung has been mistaken 
for it. Solid non-crepitant nodules or portions of lung are frequently observed 
at the autopsies of infants who have perished of severe bronchitis, and these 
may be atelectatic or pneumonic, but they are more frequently the latter than 
was formerly supposed. 

The possibility of insufflating these solid portions when removed from the 
body after death was till within a few years regarded as decisive proof of 
atelectasis. It is now known that this is not a reliable test, since a lung 
solidified by recent catarrhal pneumonitis can be almost as readily inflated as 
one which is collapsed ; but the inflated pneumonic lung is more solid and 
resisting when pressed between the thumb and fingers than is the collapsed 
lung. The decisive proof is afforded by the microscope, by which cell-pro- 
liferation is discovered within the alveoli in catarrhal pneumonitis, while it is 
lacking in simple collapse. An increase of the dyspncea not infrequently 
occurs in severe infantile bronchitis, without either pneumonia or collapse 
from the accumulation in the bronchioles of the secretion which is with 
difficulty expectorated, but if dulness on percussion and other physical signs 
indicate solidification of the lung at some point, of course pneumonia or col- 
lapse has occurred. If a sufficient amount of lung be involved to produce 
well-marked physical signs, the disease is in most instances pneumonia and 
not collapse, though it may be the latter. Both these pathological states 
may, however, occur in the same lung as complications of severe bronchitis. 
The severe paroxysmal cough of pertussis, especially when accompanied by 
considerable secretion, frequently produces collapse of portions of the lower 
lobes, while it causes emphysema in the upper lobes. 

Symptoms. — Atelectasis resulting from bronchitis gives rise to no new 
symptoms. So far as it has any appreciable effect, it aggravates certain 
symptoms of the primary disease, but as it is ordinarily limited to a small 
area, this effect is not very marked. When a bronchial tube is so occluded 
by muco-pus that the alveoli with which it communicates collapse, there is 
ordinarily at the same time more or less accumulation of this secretion in 
other tubes throughout the lungs. Therefore, the entrance of air into the 
alveoli with which these tubes communicate is slow and difficult, but usually 
without complete obstruction and without true atelectasis, but with a semi- 
collapse such as we observe in fatal croup. This explains the dyspnoea which 
is present in these cases. If the secretion be expectorated from these tubes. 



ATELECTASIS. 863 

the dyspnoea abates, even if the plug which has completely occluded a tube 
and the consequent atelectasis remain. 

Atelectasis occurring in wasted and feeble infants in consequence of the 
diminished force of the inspirations does not in most instances give rise to 
any prominent symptom, since it occurs chiefly in distant thin portions of 
the lungs. I have observed an occasional short, nearly painless, cough in 
such infants when the autopsy revealed no pulmonary lesion except the 
atelectasis. 

Anatomical Characters. — The portion of lung which is affected with 
recent atelectasis has a dark-brown or dark-bluish color. It is depressed 
below the general level of the lung, is firm and non-crepitant on pressure, and 
its incised surface is smooth. Hypersemia supervenes, because a portion of 
lung in which the circulation continues, but from which air is excluded, becomes 
congested. In acquired atelectasis the congestion is especially marked, since 
the vessels which have been adapted by growth for a larger area are com- 
pressed into one of smaller extent, so that they become tortuous and bulging 
within the lumina of the alveoli, while the free flow of blood through them 
is retarded by the constriction of the elastic fibres of the lung. An obvious 
and certain result of the hyperemia is the transudation of serum into the 
alveoli, producing oedema. This union of pulmonary hyperaemia with oedema, 
by which air is excluded from the alveoli, constitutes the state known to 
pathologists as splenization, and in proportion as it occurs the lung depressed 
by the atelectasis rises toward the general level. It may even rise above it, 
and it now has a doughy, elastic feel. The pathology of these cedematous 
atelectatic spots, heretofore obscure, has been clearly explained by Eindfleisch. 

If the patient live and the atelectatic lobules do not soon return to a 
state of health, they undergo further changes. Eindfleisch says : " From the 
series " (of changes, provided inflammation do not occur) " we especially ren- 
der prominent two conditions — inveterate oedema and slaty induration. But 
inflammation does commonly occur after a time in a collapsed lung." Those 
who are familiar with the post-mortem examination of infants will fully 
agree with Eindfleisch when he says : " Splenization, quite generally taken, 
appears to present extraordinarily favorable preliminary conditions for the 
occurrence of inflammatory changes. It may directly represent the initial 
hyperaemia of acute inflammation, and be followed by lobular and lobar, but 
constantly catarrhal, infiltrates." It is well known by pathologists that pro- 
tracted congestion, active or passive, of whatever organ or tissue, is very 
liable to pass from a state of simple stasis of blood to One of cell-prolifer- 
ation, and the atelectatic lung, as I have myself observed at autopsies, affords 
a common example of this. I have several times made or have procured 
microscopic examinations of the atelectatic portions of lungs of infants 
who had died for the most part in a wasted and enfeebled state, and have 
found in them clear evidence of the presence of a catarrhal pneumonia. 
The interesting fact therefore must be recognized that atelectasis frequently 
passes to a state of inflammation, so as to present the characters of ordinary 
hypostatic pneumonia, and no doubt undergo the same subsequent changes. 

Atelectasis when recent and simple or uncomplicated may soon disappear 
by the expectoration of the obstructing secretion, if such be present or if 
there be no obstruction by increased force of inspiration. If it do not soon 
disappear, it undergoes one of the ulterior changes alluded to above, and 
henceforth the symptoms and history are those of the new malady which 
has supervened. 

Treatment. — The treatment of acquired atelectasis is simple. If it be 
recent and there be evidence that it is due to the accumulation of the secre- 
tion in the bronchial tubes, an emetic which acts promptly and with the 



864 LOCAL DISEASES. 

least possible depression may be very useful. It is especially indicated if 
there be little or no pneumonia, the strength not greatly reduced, and there 
be dyspnoea with insufficient decarbonization of blood in consequence of the 
abundance of the secretion in the smaller tubes. An emetic which acts 
promptly and with little prostration may aid greatly in establishing the res- 
piratory function in collapsed lobules by expelling the obstruction and pro- 
ducing a freer and deeper inspiration. One of the best if not the best 
emetic for this purpose is sulphate of copper, given in a dose of one or two 
grains to a child of one year. With or without the use of the emetic, our 
main reliance must be on sustaining and stimulating measures, by which the 
cough, the cry, and the inspirations acquire more volume and force. Most 
cases require alcoholic stimulants and the ammonium carbonate. Rube- 
facient applications to the chest are also commonly employed, and are 
probably useful. 



CHAPTEE IX. 



PNEUMONIA. 



Catarrhal pneumonia is the common form of pneumonia under the age 
of three years. In most cases it results from bronchitis by extension of the 
inflammation. Hence it is designated by the terms broncho-pneumonia and 
lobular pneumonia. 

Etiology. — Catarrhal pneumonia, as we have stated above, commonly 
results from simple bronchitis. The inflammation, affecting first the larger 
bronchial tubes, extends to the bronchioles, and from them to the air-cells 
in certain lobules. Its causes under such circumstances are evidently the 
same as those of the bronchitis which precedes and accompanies it. It often 
occurs as a complication of certain infectious maladies, among which we may 
mention pertussis, measles, diphtheritic croup, influenza, and, more rarely, 
scarlatina, variola, typhoid fever, and erysipelas. Ill-nourished, rachitic, and 
anaemic children with little power of resistance are most liable to it. It is 
in the cities especially common among the children of the tenement-houses, 
who live in small, overcrowded, overheated, and dirty apartments, and are 
frequently taken from these apartments to the lower temperature of the 
streets or are exposed at open windows. Different opinions have been 
expressed as to the mode in which pneumonia supervenes upon capillary 
bronchitis. We have already called attention to the theory of Buhl, that 
the alveoli become inflamed by the entrance into them from the bronchioles, 
during inspiration, of inflammatory products, which act as an irritant. A form 
of subacute catarrhal pneumonia sometimes results from hypostasis or passive 
congestion. It is not uncommon in infant asylums in infants enfeebled by 
chronic disease, who have weak action of the heart and languid circulation. 
Lying in their cribs day after day, with little movement of the body, they 
are very liable to passive congestion of depending portions of their lungs, and 
this by and by eventuates in a pneumonia presenting some peculiarities of 
the catarrhal form. It is sometimes designated hypostatic pneumonia. It is 
so frequent in foundling asylums, where feeble infants are received and treated, 
that certain physicians, whose observations have been largely in such institu- 
tions, have almost ignored any other form of pneumonia in infants. Billard, 
a close and accurate observer, wrote nearly half a century ago : " Pneumonia 
of infancy presents peculiar characters, in which it differs from the same 
affection in adults. Instead of being an idiopathic affection arising from 
irritation developed in the pulmonary tissue under the influence of atmo- 



PNEUMONIA. 865 

spheric causes, which often excite disease, the pneumonia of young infants 
is evidently the result of a stagnation of blood in their lungs. Under these 

circumstances this blood may be regarded as a kind of foreign body 

It would therefore appear that inflammation of the lungs, which produces 
hepatization, arises in infants, in general, from some mechanical or physical 
cause.'" Yalleix also states that he found the lesions of pneumonia in a 
majority of the infants who died in the Hopital des Enfants Trouves. The 
statements of Yalleix are applicable also to the Infants' Hospital, the Found- 
ling Asylum, and the Nursery and Child's Hospital of New York City, as 
regards those cases in which death results from chronic disease. We shall 
see hereafter that hypostatic pneumonia is also a common complication of 
chronic infantile entero-colitis, the summer complaint of the cities. 

Catarrhal pneumonia of infants sometimes results from atelectasis or 
collapse. It is not unusual to find, at the autopsies of infants who have 
died in a state of emaciation and feebleness, portions of the lungs remote 
from the bronchi collapsed, as, for example, the thin edges of the inferior 
lobes and the tongue-like process of the upper lobe, the process which lies 
over the heart. The immediate cause of the collapse has been a bronchitis, 
or it has resulted directly from the general weakness of the infant and its 
feeble respirations. Now, a collapsed lung soon becomes the seat of passive 
congestion. The functional activity of an organ favors circulation through 
it, and if the function be abolished the flow of blood in the part is retarded 
and stasis more or less complete results. The hypergemic state of collapsed 
pulmonary lobules presents the same anatomical condition for the superven- 
tion of pneumonia as occurs in cases of hypostatic congestion. Consequently, 
cell-proliferation soon begins in the collapsed alveoli, the volume of the affected 
lung increases, and it becomes firmer and more resisting to the touch, and the 
microscope reveals the characters of a subacute but genuine catarrhal pneu- 
monitis. I have made or have procured microscopic examinations of a con- 
siderable number of such specimens, and have found the alveoli more or less 
filled with cells of the epithelial character. (See chapter on Atelectasis.) 
Pneumonia resulting from hypostatic congestion and that occurring from 
atelectasis are not only subacute, but usually protracted. 

Anatomical Characters. — If we have an opportunity to make a post- 
mortem inspection of the inflamed lung when broncho-pneumonia has con- 
tinued a few days, we will find the pleura covering it either normal or covered 
in spots with a thin film of fibrin. The bronchial tubes contain muco-pus, and 
their walls are thickened and congested. The inflamed lobules are few or 
many, and they are more numerous in the lower lobes and in its posterior 
portion than elsewhere. Their incised surface is not granular, as in croupous 
pneumonia, but smooth, and its color in recent cases is a pale red or deep red. 
In protracted cases the color may be grayish, but the change from red to 
gray hepatization does not occur as early as in lobar or croupous pneumonia, 
so that weeks after the commencement of inflammation in the lobule its color 
may be red. White points or lines in the lobule indicate the location of the 
bronchioles. The inflamed lobule is in some cases very distinct from the 
surrounding healthy parenchyma, but in other instances it gradually blends 
with it. 

In some cases the air-vesicles contain chiefly pus, in others chiefly epithe- 
lial cells or epithelial cells and pus, and in others still epithelium, pus, and 
fibrin. Mixed with these inflammatory products we detect also red blood- 
corpuscles. The capillaries in the walls of the vesicles are large and sinuous. 
The amount of inflammatory products in the alveoli varies greatly in different 
cases. The alveoli may be only partially filled, or they may be so packed 
that it is difficult to detect the alveolar walls. The adjacent non-hepatized 
55 



S66 LOCAL DISEASES. 

lobules do not exhibit any marked change, except that their epithelial cells 
may be somewhat swollen and more distinct than in health. The bronchial 
tubes not only contain more or less muco-pus and epithelial cells, but their 
walls are frequently thickened and infiltrated with pus-cells and connective- 
tissue cells. This infiltration causes the bronchioles to appear as white lines 
or dots in the inflamed area. 

In protracted cases the red color changes to gray, this change commencing 
in the interior of the lobules and extending outward. In gray hepatization 
the epithelial and pus-cells have undergone granulo-fatty degeneration. If 
resolution do not occur and the disease reach a still more advanced stage, the 
granulo-fatty degeneration becomes more complete, and the lobules enter the 
stage of cheesy degeneration, becoming yellowish -white and hard and homo- 
geneous, the elements which make up the lobules being no longer discernible. 
The ulterior change in the gravest cases is softening and the formation of 
cavities, or interstitial pneumonia may supervene, with an increase of the 

Fig. 240. 









'v 




Fig. 240 represents an inflamed air- vesicle from the lung of a child who died of catarrahal 
pneumonia supervening on pertussis. From Delafleld's Pathological Anatomy. 

connective tissue. Cheesy degeneration and interstitial pneumonia are much 
more frequent in lobular pneumonia, the disease which we are describing, 
than in lobar or croupous pneumonia, and when the stage of cheesy degen- 
eration is reached the conditions are present in which tuberculosis is likely 
to supervene. 

In a large proportion of instances, when broncho-pneumonia has not con- 
tinued longer than two or three weeks, the inflamed lobules can be inflated 
after death. We would infer that this would be possible in cases in which 
the alveoli are only partially filled with the cellular elements. It was for- 
merly supposed that if an infant died, having had the dyspnoea and other 
symptoms characteristic of severe bronchitis or broncho-pneumonia, and por- 
tions of the lungs were found firm and without air, if they could be inflated, 
the pathological state was atelectasis ; if they could not be inflated, it was 
pneumonia. But I have many times been able to inflate lobules that were 
undoubtedly inflamed, though when inflated they were still semi-solid on 
palpation, so that other tests besides the fact of insufflation or non-insufflation 
enable us to determine whether atelectasis or pneumonia be present. Still, 
as we have elsewhere stated, a lung primarily collapsed is very liable to take 
on a low grade of pneumonia. 



PNEUMONIA. 867 

Croupous pneumonia, also designated fibrinous and lobar, is the common 
form of pneumonia in the adult, and it is not infrequent in children over the 

Ficx. 241. 



Fig. 2-11 represents lobular pneumonia of a more severe grade, some fibrin being present in the 
centre of the air-vesicle. From Delafield's Pathological Anatomy. 

age of five years. It rarely occurs under the age of three years, but cases 
have been reported. It involves an entire lobe or a large part of a lobe. 
Besides the parenchyma, the smaller bronchial tubes also participate in the 
inflammation. Croupous pneumonia is usually a primary disease, but it is 
occasionally secondary, as, for example, when it occurs in certain debilitating 
diseases, as nephritis, or in infectious diseases, as in measles and pertussis. 

Etiology. — Formerly croupous pneumonia was commonly attributed to 
catching cold, but the microscopic examinations and experiments of Klebs, 
Friedl'ander, and Frankel have shown that this disease is microbic, and the 
two latter gentlemen, it is believed, have detected the microbe which causes 
the inflammation in ordinary cases, and they have given it the name pneumo- 
coccus. It has a breadth of about one-third its length, and it occurs in 
groups of two or more surrounded by a gelatinous envelope. According to 
the observations of Salvioli, Eberth, and Nauwerk, it appears that the 
pneumococci may also enter the general circulation, and, being conveyed to 
distant organs, may excite inflammation in them ; as, for example, nephritis, 
meningitis, and pericarditis. In ordinary cases of croupous pneumonia it is 
probable that the pneumococcus has entered the lungs by inspiration of 
infected air, and certain observers believe that it sometimes enters the 
blood and produces disease elsewhere, while the lungs escape. Croupous 
pneumonia is more common in certain years and certain seasons than in 
others. Its frequency in the spring months has been mentioned by physi- 
cians in different countries. It was common among children in April, 1890, 
in New York City after a mild and very rainy winter, the disease commencing 
suddenly with considerable elevation of temperature, and the physical signs 
of pneumonia being sufficient for diagnosis on the second, third, or fourth 



868 LOCAL DISEASES. 

day. Epidemics of croupous pneumonia sometimes occur in certain localities, 
lasting weeks or months, and there are also certain infected houses in which 
new cases of this inflammation occur during many months. In the Amberg 
prison in 1880, 161 cases of pneumonia were treated, and in the ceiling of 
the dormitory in which most of the cases occurred Keller detected pneunio- 
cocci, cultivated them, and successfully inoculated animals with them. Bad 
ventilation, overcrowding, and uncleanliness favor the occurrence of pneumo- 
nia, and epidemics have ceased when troops were removed from crowded and 
infected barracks to those that were more spacious and cleaner. 

It is the opinion of some good observers that other microbes besides the 
pneumococcus may cause croupous pneumonia — that when this form of pneu- 
monia occurs in the common infectious diseases, as scarlet fever, pertussis, 
and measles, the specific microbes of these diseases enter the alveoli and 
excite the inflammation. Prof. Prudden, who has given much attention to 
the pathology of pneumonia, expresses the opinion that while the pneumo- 
coccus ordinarily causes croupous pneumonia, it may result from other 
microbes, especially when it occurs as a complication of the common microbic 
or infectious diseases. It is a question also whether it does not sometimes 
occur without the agency of microbes — especially from taking cold, in accord- 
ance with the popular belief — and in those rare cases in which it results 
from severe injuries it seems probable that the microbe is not the causal agent. 

Anatomical Characters. — Croupous or lobar pneumonia affects an 
entire lobe or even an entire lung. Its first stage is that of congestion, which 
is characterized by distention of the arterioles and an increased afflux of blood 
to the part. In the second stage, or that of red hepatization, the lung becomes 
more solid and resisting on palpation, and at the same time it breaks down 
easily on pressure. Its color is a deep red, and its section presents the 
appearance of granules closely aggregated. Each granule is the contents of 
an air-cell. The bronchial tubes connecting with the inflamed lobule contain 
muco-pus, fibrin, and epithelium, and the pleura covering the inflamed lobe is 
coated with fibrin. 

The substance which fills the air-vesicles and gives the torn or incised 
surface of the inflamed lobe its granular appearance consists of epithelial 
cells, pus-cells, red blood-globules, and fibrin. The blood-vessels are dis- 
tended with non-coagulated blood. The fibrin usually occurs in a network. 
The epithelial cells are abundant, and they are frequently enlarged and 
granular. The pus-cells are abundant ; the red corpuscles are few, or they 
may be so abundant that they fill some of the air-vesicles. When the 
second stage, or that of red hepatization, is completed, the air-vesicles are 
entirely filled with the inflammatory products, so that in the cadaver they 
cannot be inflated. The third stage, or that of gray hepatization, gradually 
supervenes after a few days upon the stage of red hepatization, a gray mottling 
first occurring ; subsequently the gray color becomes complete. In this stage 
the same elements remain, but the congestion diminishes, the red corpuscles 
lose their color, and the inflammatory products gradually undergo granular 
degeneration. When they are filled with granules the red color is entirely 
replaced by the gray. Dr. Delafield states that the inflamed lung was found 
in this state in one-fourth of the cases examined by him. Death occurred in 
these cases between the fourth and twenty-fifth days. The stage of resolu- 
tion succeeds in favorable cases, in which the inflammatory products soften, 
liquefy, and are absorbed or expectorated. The hepatized lung, instead of 
resolving, may undergo a change identical with or closely resembling cheesy 
degeneration. It becomes dry and firm and of a white cheesy color. Epi- 
thelium, pus, and fibrin can be detected in some of the alveoli, while in others 
they are replaced by a granular mass. Again, in severe cases portions of the 



PNEUMONIA. 869 

lung may undergo necrosis in consequence of arrest of circulation. Delafield 
has observed in these cases the presence of a large amount of fibrin, and but 
little pus and epithelium. At a later stage the cavities formed contained pus. 

Fig. 242. 

fV 





Fig. 242 represents an air-vesiele from the lung of a patient who died forty-eight hours after 
the commencement of croupous pneumonia. The vesicle is only partially filled with in- 
flammatory products, on account of the brief duration of the inflammation. From Dela- 
field's Pathological Anatomy. 

This is a serious state, which is likely to eventuate in cheesy degeneration of 
the bronchial glands and tuberculosis. 

Septic or embolismal pneumonia sometimes occurs in infancy and child- 
hood, as it more frequently does in the adult, from an embolus detached from 
a clot which had formed in some remote vein, in consequence of arrest of cir- 
culation in it, by inflammation of the contiguous tissues. This is described 
by writers as a distinct form of pneumonia, designated embolic or embolismal. 
A specimen showing this mode of causation was exhibited by me at the New 
York Pathological Society in February, 1868. An infant, born January 22, 
1868, of strumous parents had been fretful, but without appreciable ailment 
till February 3d, when inflammation of the connective tissue occurred on the 
anterior aspect of the left leg, a little below 

the knee. This extended downward, sup- Fig. 243. 

purated, and the pus was evacuated February 
5th. In the mean time three other similar 
inflammations occurred — two on the right 
foot and leg, and the other over the parietes 
of the chest in the right inframammary re- |L "||^ &t\r 

gion. Suppuration occurred in all of these. |tk $M§^i t 

On February 8th this infant was suddenly ^, ^M\^3k '* *J 
seized with extreme dyspnoea, and died in a Tfe^^lHPjt^li^lB^T 
few hours. Numerous minute puriform col- iSf^*^*/*v<VV'\ " !^ „ 
lections (formerly called metastatic abscesses) *f||4 "Iftl few. ^\ fi" 
were discovered in each lung, most of them *^™§&$ Ijjgf *+ 

scarcely larger than a pin's head. One of 
them, on the right side in the middle lobe, connecting with a bronchial tube, 





870 LOCAL DISEASES. 

had ruptured into the pleural cavity, causing pneumothorax, collapse, and 
incipient pleuritis. 

Fig. 243 exhibits the microscopic appearance of this softened fibrin, which 
to the naked eye so closely resembled pus. 

On account of the speedy death the emboli had produced in the lobules 
where they had lodged little more than congestion or the first stage of pneu- 
monia around them. Had the infant lived longer, doubtless the microbes 
and ptomaines would have caused a greater amount and more advanced stage 
of pneumonia. 

Cheesy degeneration of the inflammatory product occasionally occurs in 
the croupous form of inflammation, but it is more common in the catarrhal. 
I have most frequently observed it in New York during epidemics of measles 
when this form of pneumonia supervened upon the catarrhal bronchitis of 
that disease. Cheesy pneumonia is in its nature chronic and attended with 
great reduction of the vital powers. 

Cheesy degeneration of the exudate consists essentially in the absorption 
of the liquid portion and fatty degeneration of the solid. The obstruction 
of the circulation in the capillaries and the accumulation of cells in the 
alveoli and bronchioles which cannot be expectorated are conditions which 
favor cheesy metamorphosis. The appearance and consistence of the lung 
when it has undergone this change are well expressed by the term which is 
employed to designate it. The cheesy mass consists of fatty, shrivelled, and 
fragmentary cells, and amorphous matter in which can be traced the fibres 
of connective tissue and larger vessels of the parenchyma, the other histo- 
logical elements having disappeared. 

The caseous mass after a time softens, attracting moisture from the sur- 
rounding tissues. The molecular detritus and the shrivelled cells are now 
suspended in a liquid, and, like any dead matter, they are irritant to the sur- 
rounding lung-substance. The bronchial tube which supplies the affected 
lobule, and which in many instances was the starting-point of the disease, 
again becomes pervious, either by softening of the plug or by ulceration at 
a higher point upon its walls and air is admitted, which promotes the putre- 
factive process and chemical changes of the caseous substance. 

The presence of softening caseous matter in the lungs very frequently 
leads to the development of tubercles (see chapter on Tuberculosis), and 
accordingly before the case ends clusters of tubercles may appear in the 
connective tissue and walls of the vessels of the lungs and in other organs. 

The symptoms of acute pneumonia, whether catarrhal or croupous, are 
the following : Anorexia, thirst, restlessness, elevation of temperature, accel- 
eration of pulse according to the intensity of the inflammation and the fee- 
bleness of the patient, flushed face, a countenance expressive of suffering, 
accelerated respiration, with an expiratory moan. These symptoms are con- 
stant in the acute inflammation unless of the mildest form. Those which 
are important I shall explain more fully. 

The expiratory moan is described by writers as a pathognomonic sign 
of pneumonia or of pleurisy. It is due to the pain experienced from the 
movement of the inflamed part. As a rule, the expiratory moan indicates 
either pneumonia or simple pleuritis ; but there are exceptions. It may 
occur, for example, from indigestible substances in the stomach and intes- 
tines, giving rise to acute dyspepsia, or from certain forms of abdominal 
inflammation which render movements of the diaphragm painful, as dia- 
phragmatic peritonitis. 

The cough in the first days of pneumonia is usually dry or hacking and 
painful. It afterward, if the case be favorable, becomes looser and is pain- 
less. We very seldom observe in the child the bloody sputum which cha- 



PNEUMONIA. 871 

racterizes pneumonia in the adult, since in catarrhal inflammation there is 
much less exudation of blood-corpuscles. The sputum, which in this form 
of the disease is the product of secretion and cell-proliferation, is at first thin 
and frothy, but afterward thicker and less tenacious from the increased num- 
ber of cells. There is often, in the first period of the inflammation, pretty 
severe and constant headache, the patient complaining of the head, if old 
enough to speak, before he does of the chest. In a severe attack, the child 
at this period lies with the eyes shut, apparently in a half-conscious state, 
fretful if spoken to or aroused, so that the physician may be led to suspect 
the presence of cerebral disease. If there be vomiting accompanied with 
sudden twitching of the muscles and convulsions — symptoms which some- 
times occur — the liability to error in diagnosis is greatly increased. Cerebral 
symptoms are more prominent in the commencement of pneumonia than sub- 
sequently. As the disease advances they subside, and symptoms referable to 
the chest become more conspicuous. 

The breathing is, as I have said, accelerated. Thirty or forty respirations 
per minute are common, and in severe cases the number reaches sixty or even 
eighty. In infancy there is greater frequency of respiration than in child- 
hood. In those at the breast, if the dyspnoea be urgent, nutrition is some- 
times seriously interfered with, since in these severe cases respiration is per- 
formed more through the mouth than nostrils, so that if the infant seize the 
nipple it is forced to relinquish it in order to breathe. Dilation of the alae 
nasi and depression of the inframammary region accompany inspiration. The 
dyspnoea in catarrhal pneumonia is often due in great part to accompanying 
bronchitis. 

The temperature in mild cases of pneumonia is elevated to about 101° to 
103° ; in severe cases it may reach 105°, or even 107°, the former being the 
highest observed by Mr. Squire. In 97 observations made by M. Roger the 
average temperature was 104° during the active period of the inflammation. 
The face is therefore flushed and the heat of surface pungent, except in 
weakly children, in whom, even in severe and active inflammation, the face 
is sometimes pallid and the extremities of natural or less than natural 
temperature. 

The tongue is moist and covered with a light fur ; the thirst is such that 
nutriment may be given in the form of drinks when the loss of appetite pre- 
vents the use of solid food. The bowels are usually constipated. The secre- 
tions in the first and second stages are diminished. The urine is more deeply 
colored than in health, and in vigorous patients it deposits urates on cooling. 
The chlorides are also deficient or absent from the urine so long as the inflam- 
mation is extending. 

In favorable cases in from seven to ten days the heat and thirst decline ; 
the pulse and respiration gradually become less frequent ; the cough looser ; 
the features have a more placid or contented expression ; the appetite 
returns ; and the patient is again amused by playthings. The improvement 
is progressive, but gradual. A slight cough is occasionally observed two or 
three weeks after convalescence is fully established. 

Death in the acute stage of the inflammation commonly occurs from 
asthenia. The pulse gradually becomes more frequent and feeble, the respi- 
ration more oppressed, and finally, near the close of life, the face and extrem- 
ities become cool. Occasionally death results from apnoea, due in great part 
to coexisting bronchitis. In exceptional instances it occurs from convul- 
sions, followed by coma, especially in the first week. In those protracted 
cases in which the inflammatory products have undergone cheesy degenera- 
tion death occurs from asthenia. 

Such are the symptoms and progress of ordinary acute pneumonia in 



872 LOCAL DISEASES. 

children. When the inflammation is subacute, as in those forms of the dis- 
ease which result from collapse or hypostasis, the symptoms are less pro- 
nounced. The respiration in such cases is but moderately accelerated, is 
attended by little pain, and therefore the expiratory moan is often absent. 
An occasional short, dry cough occurs, with so little increase of temperature 
and quickening of the pulse that the pneumonia is often overlooked by the 
physician, the symptoms being referred to bronchitis. Pleuritis seldom occurs 
in connection with this form of pneumonia, except when a small abscess or 
gangrene results in an affected lobule directly under the pleura. A few 
such cases I have observed. 

Tubercular pneumonia extends over much or little of the lung accord- 
ing to the amount of the tubercles. The symptoms are like those of 
severe primary pneumonia, superadded to such as pertain to tuberculosis. 
This inflammation, when once established in the consumptive child, com- 
monly continues till the close of life. I have sometimes had these cases 
under observation several consecutive weeks, even months, and during the 
whole time there was not only acceleration of pulse and respiration, but the 
expiratory moan. As regards pneumonia occurring in whooping cough, it is 
an interesting fact that it sometimes modifies the symptoms of the primary 
disease, so that during the active period of the inflammation the paroxysmal 
cough diminishes, and a short, hacking cough and expiratory moan occur in its 
place. As the inflammation abates the spasmodic cough returns. Pneumo- 
nia occurring in measles is more obstinate, protracted, and dangerous than 
the primary form. It usually commences about the period of the decline of 
the eruption, and in favorable cases continues two or three weeks. It is 
then a sequel rather than a complication. 

Physical Signs. — The physical signs of pneumonia in infancy and 
childhood are the same as in the adult, but in a large proportion of cases 
they are less distinct. In a majority of patients under the age of three 
years the crepitant rale is not observed. This is due to the small size of the 
alveoli at this age. I have now and then detected it in quite young children, 
in whom it is a finer rale than in the adult. If observed it is positive proof 
of the existence of pneumonia. The physical signs, therefore, in the first 
stage of the inflammation are often obscure in consequence of the absence 
of the pathognomonic rale. The vesicular murmur is somewhat intensified 
through the chest, and there is at this stage slight dulness on percussion 
over the seat of the inflammation, due to engorgement of the vessels, but it 
is difficult to appreciate this. 

In the second stage, which supervenes more or less rapidly, the physical 
signs are more distinct. Bronchial respiration is in most cases detected 
higher in pitch than the vesicular murmur, with the sound of expiration 
higher than that of inspiration. The voice of the patient is transmitted to 
the ear applied over the seat of the disease, and often a peculiar vibratory 
sensation is communicated to the hand applied over the part, so that it is 
possible to locate the disease by palpation alone. In the second stage, and 
sometimes in the first, coarse mucous rales in various parts of the chest are 
often observed occurring from coexisting bronchitis. 

Percussion in the second stage elicits a dull sound as compared with that 
produced on the opposite side of the chest. The dulness corresponds in 
extent with the solidification and with the bronchial respiration. 

As the inflammation abates the dulness on percussion gradually dimin- 
ishes, and the bronchial respiration is succeeded by the subcrepitant rale. 
Often for a considerable period after convalescence is established moist rales 
are observed in the chest, and sometimes the dulness on percussion does not 
entirely disappear until the health is fully restored. 



PNEUMONIA. 873 

In catarrhal pneumonia these signs are commonly less distinct than in 
the croupous form of inflammation. This is due in part to the limited 
extent of the inflammation, in part, in many cases, to its subacute character, 
and in part to the fact that it is in many patients double, so that we lose the 
aid of comparison. When it results from hypostatic congestion it is nearly 
always bilateral. 

Diagnosis. — It will aid in diagnosis to recollect that under the age of 
three years pneumonia is ordinarily catarrhal, and that it is preceded by and 
associated with bronchitis. Coincident with it, and often preceding its devel- 
opment for a few days, are the usual symptoms of nasal and bronchial catarrh. 
Defluxion from the nostrils and other symptoms due to " taking cold " help 
us to diagnosticate catarrhal pneumonia from the essential fevers, with 
the exception of measles. Croupous pneumonia begins more abruptly, but 
in this form of inflammation the greater extent of pulmonary solidification 
soon gives us clear and unmistakable physical signs. The various forms of 
so-called remittent fever bear considerable resemblance as regards symptoms 
to certain cases of pneumonic inflammation, but in the latter there are more 
acceleration of respiration and greater suffering, especially when the child 
is disturbed, than in the former. The physical signs, however, afford decisive 
proof of the nature of the malady — to wit, dulness on percussion, bronchial 
respiration of a higher pitch and harsher than the normal vesicular respi- 
ratory sound, bronchophony, vocal fremitus, etc. 

Difficulty sometimes attends the diagnosis of broncho-pneumonia from 
simple bronchitis. The presence of the expiratory moan, if it be pretty 
constant and marked, affords evidence that the inflammation has extended to 
the lungs, but the physical signs constitute the reliable means of exact diag- 
nosis. They should be carefully noted, in order to determine if there be 
some point of solidification. 

Solidification gives rise to dulness on percussion, bronchial respiration, 
and bronchophony. These three signs coexisting afford sufficient proof of 
pneumonia, unless there be tubercular consolidation or possibly collapse super- 
vening on suffocative bronchitis. The history of the case aids in determining 
whether there be either of these diseases. Moreover, collapse occurs later 
after the attack commences than hepatization, and does not produce so 
distinct bronchophony or bronchial respiration as is observed in ordinary 
cases of pneumonia. 

Pleuritis with effusion may present physical signs which bear consider- 
able resemblance to those in pneumonia ; but in pneumonia, except when 
associated with tubercular disease, the dulness on percussion is not so great 
as that from pleuritic effusion. In pleuritic effusion in a young child the 
respiratory murmur can often be heard with the ear applied over the liquid, 
but it is indistinct and transmitted through the liquid from a distance. The 
practised ear is able to discover the difference between it and the bronchial 
respiration of pneumonia. Vocal fremitus, which is absent in pleuritic effu- 
sions, is another reliable sign of pneumonia in children over the age of three 
or four years. In younger children it is indistinct. Occasionally the physical 
signs indicate the coexistence of the pulmonary and pleural inflammations. 

In catarrahal pneumonia it is often difficult to determine certainly the 
nature of the disease, since the physical signs, if there be but little extent 
of inflammation, are absent or indistinct. I have often, in post-mortem 
examinations, found so small a part of the lung hepatized that it could not 
possibly have produced any appreciable dulness on percussion, bronchial 
respiration, or bronchophony. Such cases often pass for simple bronchitis, 
and practically this matters little, since the treatment required by the two 
is not dissimilar. 



874 LOCAL DISEASES. 

Prognosis. — Primary pneumonia, affecting only one lung, if properly 
treated in most instances terminates favorably in children and even infants. 
If double, it is, as in the adult, much more serious, and is in certain cases 
fatal. Secondary pneumonia, pneumonia occurring in measles, whooping 
cough, tuberculosis, or resulting from hypostatic congestion in the course 
of some exhausting disease, is, on the other hand, more frequently fatal. 
As death usually occurs from asthenia, the younger the child and more 
feeble the constitution the greater the danger. 

Unfavorable symptoms are an increase of dyspnoea, a pulse becoming 
more and more frequent and feeble, pallor of countenance, inability of the 
patient to support the head, total loss of appetite, refusal to notice or be 
amused by playthings, absence of tears when crying — a symptom which 
French writers have pointed out — and the appearance of pemphigus on the 
face or elsewhere. 

Indications on which a favorable prognosis may be based are moderate 
acceleration of pulse and elevation of temperature, pneumonia primary and 
limited to one side, ability to support the head or sit erect, being amused 
by playthings, etc. 

Treatment. — The treatment of the two forms of pneumonia — namely, 
catarrhal and croupous, the former occurring chiefly under the age of three 
years and being secondary, the latter occurring in most patients over that 
age — requires to be considered separately, as much as do their symptoms 
and anatomical characters. 

Catarrhal pneumonia, when developed from and upon a bronchitis, as it 
so often is, requires for the most part the continuance of the remedies which 
are appropriate for the primary disease. (See chapter on Bronchitis.) But 
from the fact that it is secondary and in children of tender age, and since 
the danger as regards the pneumonia is due to asthenia, more actively sustain- 
ing measures are demanded than are required for uncomplicated bronchitis. 
When the pneumonia has continued a few days, and often in its commence- 
ment, carbonate of ammonium and alcoholic stimulants are needed, and the 
diet from the first should be nutritious. In that form of catarrhal pneumo- 
nia which is due to passive congestion or hypostasis, in the causation of 
which debility is an important factor, tonic and stimulating measures are 
imperatively required. Frequent change of position is useful in such 
cases. 

In croupous pneumonia, if seen at the commencement or within a few 
hours of the commencement, an emetic of ipecacuanha may be given, as 
recommended by Trousseau. This acts promptly as a cardiac sedative, 
diminishing somewhat the afflux of blood to the lungs and moderating the 
inflammation. It should not be employed except at the period mentioned. 

The abstraction of blood by leeches or otherwise has justly fallen into 
disrepute in the treatment of the inflammations of children, since it is too 
depressing. We have in aconite and phenacetin efficient substitutes for 
bloodletting, which by their sedative effect on the heart diminish the 
exaggerated afflux of blood to the inflamed lung, and thus enable us to 
meet the indication of treatment in the first stage of the inflammation. It 
is important in all severe cases to preserve the blood and the strength, for 
the danger in the end is chiefly from asthenia, and therefore the use of one 
of the cardiac sedatives mentioned above is preferable to the abstraction 
of blood. 

The following prescription will be found useful in the commencement 
of pneumonia, when the child is restless and has the expiratory moan. It 
is especially useful if, in addition to the general restlessness, occasional 
twitching of the limbs occurs, which is a forewarning of eclampsia : 



PXEUMONIA. 875 

R. Tine, opii deodorat, gtt. xvj ; 

Phenacetin, gr. xvj ; 

Potas. bromidi, 5j ; 

Syr. simplic., gss ; 

Aqua? anisi, ^iss. 

Shake bottle. Give one teaspoonful every two or three hours to a child of two to 
three years. If nervous symptoms are not prominent, the bromide may be 
omitted. 

If bronchial respiration, bronchophony, and dulness on percussion are 
present, indicating the second stage of pneumonia, it is better to discontinue 
the use of the antipyrine or other cardiac sedative, unless the temperature 
reach or exceed 10-1°. If it do, one grain of phenacetin may still be admin- 
istered every third hour to a child of two years, and two grains to one of 
three or four years. 

The remarks made in reference to the use of quinia and digitalis for 
bronchitis apply with still more force to their use in both the catarrhal and 
croupous forms of pneumonia, In secondary pneumonia, and in primary 
occurring in feeble children, these agents are in many instances preferable to 
any other medicine for the purpose of reducing the temperature and pulse, 
since they produce this result without depression. They may be administered 
in such cases from the first day. 

In some observations recently made (1880-81) in the New York Found- 
ling Asylum it seemed to us probable that quinine, given in one or two large 
doses at the commencement of acute primary pneumonia, as five grains to 
a child of three years, exerts some controlling effect on the inflammation, 
perhaps even aborting it. 

When the inflammation begins to abate there is usually progressive 
improvement, Many now recover with simple mucilaginous drinks or mild 
expectorants useful for the accompanying bronchitis, as chloride of ammo- 
nium in the syrup of tolu. Others require more sustaining measures, and for 
such carbonate of ammonium is preferable, with, perhaps, quinia. In severe 
pneumonia it is of the utmost importance to sustain the vital powers, even 
from the commencement of the inflammation. There can be no doubt that 
the great error in the therapeutic management of children with this malady 
has been the employment of medicines which reduce the strength when 
gentler measures or those of a sustaining nature were needed. Alcoholic 
stimulants are required sooner or later in most cases. They should be pre- 
scribed from the first in feeble children and in secondary forms of the inflam- 
mation. Infants may take three or four drops of Bourbon whiskey or brandy 
for each month of their age every two or three hours. The diet should be 
nutritious, consisting of milk, animal broths, and the like, unless during the 
first three or four days in robust children. 

The bowels should be kept open as an important part of the treatment of 
croupous pneumonia in its first stages. In robust children a small dose of 
castor oil, Rocheile salts, or citrate of magnesia should be given if there be 
any tendency to constipation, and subsequently a daily evacuation should be 
produced by a clyster or otherwise. A saline aperient by its derivative and 
refrigerant effect in some cases obviates the necessity of employing cardiac 
sedatives. A laxative enema is preferable for a feeble child and in most 
cases of secondary pneumonia. 

Local treatment is required in most instances. Counter-irritation should 
be produced over the chest by measures which differ according to the age. 
The following are useful formulae for external treatment : 

K. Olei camphorati. 



876 LOCAL DISEASES. 

For a child of three months muslin soaked with the oil should be applied 
over the chest, and then covered with cotton batting and perhaps oil-silk. 

R. Olei caryophylli, ^ij ; 

Olei camphorati, §iv. — Misce. 

For external use at the age of six months, applied by muslin soaked with it and 
covered by oil-silk. 

For children over six months the following : 

R. Pulv. sinapis, §j ; 

Semen, lini, S xv j' 

For external use. 

In cheesy pneumonia, which is always accompanied by anaemia and great 
reduction of the vital powers, the carbonate of ammonium in milk or a syrup 
to prevent irritation is useful, as is also the inhalation of the vapor of the 
following from a sponge : 

R. Creasoti (Morson's beech wood), ^ij ; 

Terebene, Jiij. 

Add twenty-five drops to the sponge of the perforated zinc inhaler, and 
employ several times daily. Creasote given internally in cod-liver oil or 
in orange-juice is also recommended for those cases in which tuberculosis 
is likely to occur. 



CHAPTER X 

PLEUKISY. 



The term pleurisy or pleuritis is employed in this chapter to designate 
inflammation of the pleura when not produced by extension of the inflamma- 
tory process from the lung or by the irritation of tubercles upon or under the 
pleura. Catarrhal pneumonia, common in infancy ; croupous pneumonia, 
common in childhood ; pulmonary tuberculosis, not rare in both periods in 
wasted and cachectic children, — are ordinarily accompanied by pleurisy, 
arising consecutively to the lung disease, and limited nearly to the portion 
of the pleura which covers the affected lobes or lobules. But since in these 
cases the pleuritis is subordinate to and dependent on the graver diseases, and 
is comparatively unimportant, it does not require separate consideration. It 
is properly treated of in our books in connection with and as a part of those 
diseases. All other cases of pleuritic inflammation, although presenting wide 
differences in form and clinical history, are embraced under the general term 
pleurisy. 

Frequency. — Pleurisy was formerly supposed to be rare in young chil- 
dren. Even M. Barrier of Lyons, the author of a creditable treatise on dis- 
eases of children, wrote as late as 1860 : " Ainsi done, en generalisant les 
faits de Vallieux et les notres, nous pouvons dire : que la pleurisie, depuis la 
naissance jusqu'a l'age de six ans environs, ne constitue presque jamais une 
affection simple, unique, et independante de la pneumonic" But greater 
precision in the examination of cases, more accurate means of diagnosis, more 
knowledge of the nature of diseases, and more frequent autopsies have 
enabled the profession to correct this as well as many other errors, and it 



PLEURISY. 877 

is now known that* primary pleurisy is not infrequent in young children, 
even in infants. In asylums and hospitals for children, in which institutions 
the nature of diseases is more accurately ascertained than in private prac- 
tice^ — for autopsies are made in the fatal cases — the frequency of pleurisy in 
its various forms, latent, semi-fibrinous, and purulent, is surprising to those 
whose knowledge of the disease has been acquired only through private prac- 
tice. Thus, in the Xew York Foundling Asylum in the seven months from 
April 1 to November 1, 1879, while there were 35 cases of bronchitis, 21 of 
pneumonia, and 3 of tuberculosis, there were 11 clearly-ascertained cases of 
pleurisy. There can be no doubt that many cases of this malady in young 
children are mistaken by good practitioners for other diseases, especially for 
pneumonia, or, if the pleurisy be to a certain extent latent, for remittent or 
malarial fever or fever due to intestinal irritation. I have records of several 
cases occurring in family and hospital or asylum practice in which children 
perished with a wrong diagnosis or without diagnosis, when the post-mortem 
examination revealed pleurisy, sometimes of long standing. Thus in one 
case of fatal empyema, commencing at the age of six months and continuing 
several months, chronic pneumonia had been diagnosticated by physicians 
known to be thorough in their examination and usually accurate. In another 
case, which proved fatal at about the age of one year, the child, who lived in 
a malarial locality, had been for weeks under treatment for supposed malarial 
disease ; but in this case diagnosis was easy, for at my first visit, which was 
when the child was dying, there was decided dulness on percussion over 
the right side of the chest. In this case the right lung was adherent to 
the ribs anteriorly and laterally, while posteriorly it was separated by pus, 
which crowded forward the organ so that its posterior surface was concave. 

In wards of institutions and in the crowded quarters of the poor pleurisy 
appears to be more frequent than in families in comfortable circumstances. 
Its frequency varies also in different years according to the presence and 
prevalence of its causes. Thus during epidemics of scarlet fever it is more 
common than at other times. 

During several weeks immediately preceding May, 1874, when there was 
no unusual prevalence of the causes or conditions which give rise to pleurisy, 
I noted carefully the character of the sickness in 404 consecutive cases under 
the age of twelve years in private practice, and of these 2 had primary 
pleurisy, or J per cent. This is probably about the usual proportion of 
pleurisies in children in family practice, except when scarlet fever is 
prevalent. 

I have preserved the records of 56 cases of pleurisy in children under 
the age of twelve years, most of them occurring in the institutions which I 
am attending or have attended as physician, and the remainder in private 
practice. The statistics of these cases, embraced in the following table, are 
interesting, as showing the frequency of pleurisy, and pleurisy of the suppura- 
tive form, in young children. The large number of empyemas seen in the 
table does not, however, indicate the true proportion of suppurative to sero- 
fibrinous pleurisies, since protracted and stubborn cases, which are largely 
empyemas, are more frequently brought to institutions for treatment than are 
those of a milder and more manageable type. Thus, in the class of children's 
diseases in the Bureau for the Relief of the Out-door Poor a large percentage 
of the cases are empyemas which have resisted treatment elsewhere. Besides, 
pleurisy with little exudation is sometimes latent or so mild that it is over- 
looked or not diagnosticated even by physicians who are thorough and careful 
in their examinations, and I do not doubt that such cases have occurred in the 
institutions and in my private practice during the time in which my statistics 
were collected : 



878 



LOCAL DISEASES. 

Age (Jf.9 Cases). 



Under two 
months. 



3 ; all empy- 
emas ; 1 
double. 



From two to six 
months. 



15 ; 9 at least 
empyemas — 7 
on right side, 
4 on left side, 
4 double. 



From six to [From one year 
twelve months, to three years. 



2 ; both em- 
pyemas — 1 
right, the 
other left. 



13 ; 8 right, 
5 left. 

Exudation in 
some sero- 
fibrinous ; 
in others, 
purulent. 



From three 

years to six 

years. 



10 ; 7 right, 
3 left. 

Exudation in 
some sero- 
fibrinous ; 
in others, 
purulent. 



Over six years. 



6 ; 5 right, 1 
left ; 1 em- 
pyema. 



Causes. — Primary pleurisy in the child has heretofore been attributed 
to that common cause of inflammations, " taking cold." It is often most 
common in times of changeable temperature. Cachexia is an acknowledged 
predisposing cause, so that children whose blood is impoverished, whether 
from previous disease or from antihygienic influences, are more liable to this 
inflammation than those who possess a sound and vigorous constitution. 
From the operation of this cause a larger proportion of cases occur among 
the children of the city poor than among those who are well nourished and 
who live in comfortable circumstances, since the cachectic and ill-cared-for 
are not only more exposed, but are less able to resist noxious agencies. 

Pleurisy is not rare in new-born infants, and its cause when thus occur- 
ring is not always apparent. It may sometimes be heedless exposure to cold 
or to currents of air by the nurse, but the common cause at this age is 
believed to be the absorption of septic matter. 

Billard, whose observations were made among foundlings in the Hospice 
des Enfants Trouves, says : " Pleurisy is more common among young infants 
than is generally supposed ; it often appears without the lungs participating 
in the inflammation. I have seen several infants die immediately after birth 
from this affection." He relates two cases of double idiopathic pleuritis end- 
ing fatally at the ages of two and ten days {Diseases of Infants, page 419). 
Mignot, whose observations were made in the same institution, also records 
16 pleurisies, 5 of which were idiopathic, in 119 dissections of new-born 
infants {Maladies pendant Je Premier Age). 

Cases like the following are not infrequent : 

In 1867, I made the post-mortem examination of a foundling who died in 
the New York Infant Asylum at the age of about one month. On each side 
of the thorax, the pleura, costal and pulmonary, was uniformly injected, and 
a small amount of pus, not more than one drachm, was found in one pleural 
cavity, and a still less quantity of pus in the other, with little or no sero- 
fibrinous exudation. There was also pus at the root of each lung, lying not 
entirely upon the free surface of the pleura, but partly underneath it. 

The fact of a double pleurisy without disease of the lungs, which might 
produce it, indicated a constitutional cause. Its system had probably become 
infected by the absorption of septic matter from the umbilical vessels. 

One of the eruptive fevers, scarlatina, not infrequently produces pleurisy, 
occurring as a complication or sequel. This result seems to be sometimes 
due to septic matter in the blood resulting from the action of the scar- 
latinous virus. In other instances it is possibly the result of retained urea 
consequent on scarlatinous nephritis, for pleurisy is a common complication 
of Bright's disease, due, it is supposed, to the irritating property of urea, 
which is excreted upon the pleural surface. Pleurisy in young children is 
sometimes also caused by the discharge into the pleural cavity of some mor- 



PLEURISY. 879 

bid product, as pus. softened tubercle, or decomposed lung-tissue, which from 
its highly irritating effect causes intense and general inflammation of the 
pleura. I have observed several such cases. 

Thus, in November. 1866, an infant of three and a half months died of 
pleurisy occurring upon the left side. The left lung was firmly bound down 
bv adhesions, so as to be reduced to about one-sixth its normal size. On 
attempting inflation of this organ when it was removed from the body, air 
escaped from a small opening in the middle of the upper lobe, and around 
this opening the lung-substance was of a dark reddish color, softened and 
disintegrated. It seemed probable from the appearance that there had been 
hypostatic congestion, or perhaps pneumonia, in the posterior part of the 
lung, and that the loss of vitality and softening had occurred from the slug- 
gish or suspended circulation in the part, and that the fatal pleurisy had 
resulted from a little of this decomposed tissue entering the pleural cavity. 

A case having apparently a similar origin occurred in the New York 
Foundling Asylum in October, 1879 : 

An infant aged five months and a half became suddenly and severely 
sick with pleurisy on the right side, and died in five days. On opening the 
pleural cavity, air escaped. The record of the examination states : " In 
about the middle of the posterior surface of the lower lobe was an opening 
which admitted the tip of the little finger to the depth of one-fourth to one- 
third inch. The lung-tissue was disorganized and of pultaceous consist- 
ence around the cavity. Through this cavity, which communicated with a 
bronchial tube, the air had escaped, which was noticed on opening the 
chest."' 

Occasionally we meet cases, especially in foundling asylums, in which 
the cause is different from the foregoing, but in some respects similar. An 
indolent pneumonia occurs over a circumscribed area in the posterior part 
of the lung, either from hypostasis or exposure to cold. Minute abscesses 
form in the inflamed parenchyma, not larger than pins' heads or small shot. 
Perhaps they are located in bronchioles, and are produced by the accumula- 
tion of muco-pus, which collects in these tubes, and is not expectorated on 
account of the low vitality and feeble functional activity of the tissues con- 
cerned. These abscesses approaching the pleural surface produce a circum- 
scribed pleurisy of small extent ; and finally one, probably in some sudden 
movement of the lungs, as in crying or coughing, breaks into the pleural 
cavity, causing general purulent inflammation. The following was such a 
case : 

In May, 1859, a male infant aged two months was admitted into the 
Nursery and Child's Hospital. He was delicate, and had what was diag- 
nosticated a mild bronchial catarrh, but by wet-nursing his general condition 
gradually improved. In July, however, he had repeated attacks of diarrhoea, 
and progressively lost flesh and strength. On August 3d his respiration 
became suddenly accelerated and painful, and death occurred from dyspnoea 
and exhaustion. No cough or other symptom referable to the respiratory 
apparatus had been observed previously to the day of death. 

At the autopsy the intestines were found to present the usual lesions of 
intestinal catarrh of the summer season. The right lung was compressed by 
a sero-fibrinous exudation, though, from the small size of the pleural cavity, 
the quantity of exuded liquid was not more than two ounces. Nearly the 
entire right pleura, visceral and parietal, was covered with fibrin of a creamy 
appearance, and there were loose flocculi in depending portions of the cavity. 
This lung could be inflated, except a little of the lower lobe, which was hepa- 
tized. The left lung also occupied a very small space, being partially col- 
lapsed. It could be readily inflated, when it appeared normal, except a small 



880 LOCAL DISEASES. 

portion in the posterior aspect of the lower lobe, which was partially covered 
with lymph, and was found to contain two abscesses, one closed and the other 
opening externally on the surface of the lung and connecting internally with 
the bronchial tube. On attempting inflation air passed directly through this 
opening. The closed abscess contained from one-third to one-half a drachm 
of pus and disintegrated lung-tissue, as shown by the microscope. 

Another case, showing a similar cause of pleurisy, occurred in a female 
infant of about four months, in the same institution, in November, 1869 : 

She was admitted in October, somewhat reduced from diarrhoea, but her 
health improved partially, though she remained feeble, and the records state 
that she was much troubled with meteorism and occasional pain. On Novem- 
ber 2d she was suddenly seized with great dyspnoea, and died in about fifteen 
minutes. No cough had been noticed or other symptom referable to the 
chest, but there can be little doubt that the occasional symptoms of pain 
referred to in the notes were due to the pleurisy. The body was much 
emaciated, and depending portions showed hypostatic congestion ; right lung 
adherent to diaphragm and to a considerable part of the costal pleura by 
fibrinous exudation ; this lung was somewhat compressed and non-crepitant ; 
its upper lobe floated in water, while its middle and lower lobes sank and 
could be only partially inflated ; this portion of the lung contained a few 
small superficial abscesses, each holding scarcely more than one drop of pus ; 
two of these were empty, and air passed through them on attempting infla- 
tion. They probably, one or both, opened into the pleural cavity during life, 
but possibly they were opened in separating the adhesions which united the 
two pleural surfaces at this point ; the pleural cavity contained from two to 
three ounces of liquid, consisting mainly of pus and fibrinous shreds. 

A similar case occurred in the New York Foundling Asylum in October, 
1879 : 

The patient, aged four months, began to be sick October 11th, having 
the characteristic symptoms, and died October 15th. The right pleural 
cavity contained about ^iij of sero-purulent liquid, pressing the lung forward 
and toward the median line. In the posterior surface of the right lower lobe, 
near its base and immediately under the pleura, were three or four small 
abscesses, each not larger than a small drop of pus, and two or perhaps three 
of these had ruptured, so that air escaped from them on attempting inflation, 
while one was closed, the pus in it being visible under the pleura. 

This cause of pleurisy — namely, the bursting of a minute abscess in the 
lung — and that in which a portion of the lung loses its vitality, disintegrates, 
and enters the pleural cavity, are probably not frequent, except in the first 
months of infancy in wasted and ill-conditioned infants in families of the city 
poor and in the asylums. 

A peripharyngeal abscess, descending along the oesophagus, has been 
known to cause fatal pleuritis by bursting into the pleural cavity, and pus 
from carious vertebrae has produced the same result. In January, 1864, I 
presented to the New York Pathological Society the lungs of an infant whose 
history was as follows : 

R , aged nine months, of strumous parentage, and whose only sister 

had suffered severely from strumous ophthalmia and periostitis, was taken 
sick about December 19, 1863, with febrile symptoms, attended by restless- 
ness, but apparently without any serious indisposition. On the 22d the 
mother called my attention to a prominence just below the right clavicle, 
which proved to be an abscess, and a poultice was applied over it. On the 
24th the prominence suddenly subsided, and immediately the symptoms were 
greatly aggravated. The pulse rose to 160 per minute, the respiration from 
60 to 80, and expiration was accompanied by a moan, indicating acute pleu- 



PLEURISY. 881 

ritic inflammation. "Within forty-eight hours after the disappearance of the 
swelling and the exacerbation of symptoms dulness on percussion over the 
right side of the chest was observed, and this increased till it was complete 
from the clavicle to the base of the thorax. The acceleration of pulse and 
respiration continued, the patient grew more and more feeble, and death 
occurred December 31st. 

On dissecting away the integument from the right side of the chest an 
abscess was opened containing nearly one ounce of pus, located at the point 
where the tumor had been observed. At the base of this abscess, between 
two of the ribs, was a small round opening, not much larger than a knitting- 
needle, leading directly into the cavity of the chest, so that on depressing 
the ribs liquid flowed from the pleural cavity. On removing the sternum 
the liquid was found to be sero-fibrinous, with considerable pus in depending 
portions of the pleural cavity. 

I have met one other, apparently almost identical, case, occurring in an 
infant of seven months. 

Pleurisy in the adult is sometimes the result of violence. The most 
notable and unequivocal cases having this origin are those in which the ribs 
are fractured. It rarely happens that we can attribute the pleurisy of chil- 
dren to this cause. I can recollect only one case in which the inflammation 
seemed to be due to violence : 

In September, 1867, an infant of twenty-two months in the almshouse 
on Blackwell's Island, having had a cough half a year and being some- 
what reduced, fell from bed, striking against the left side of the thorax. 
Severe pleuritic symptoms supervened, and the child died of empyema in 
three and a half weeks. More than a pint of pus was found in the left 
pleural cavity, pressing the heart beyond the median line and the diaphragm 
downward, so that it was convex toward the abdomen. The bronchial glands 
were hyperplastic and slightly cheesy, and a caseous nodule lay in the anterior 
surface of the right lung, which seemed otherwise healthy. The left lung, 
bound down by adhesions, could be partially inflated. Whether or not it con- 
tained small tubercles is not stated in the records. 

The occurrence of the injury just before the commencement of the pleu- 
risy may indeed have been a coincidence, but the mother constantly believed 
that the fall caused the inflammation, and there was no other assignable 
cause. 

It is probable, from the history of this case and the lesions, that the 
cheesy degenerations antedated the fall, and that the pleura was in an abnor- 
mal state and prone to inflammation when the injury was received. 

The etiology of pleurisy in children differs, therefore, from that in adults. 
Certain causes are the same ; but others, as scarlet fever and irritating 
products generated in the walls of the chest and bursting into the pleural 
cavity, are not rare in infancy and childhood, while they seldom occur in 
adults. 

Histories of cases like the above strengthen the belief that pleurisy in 
children frequently, and perhaps usually, has a microbic origin. This belief 
also receives support from the researches of Dr. Henry Koplik of New York. 
An interesting and instructive paper detailing his investigations was read 
before the American Pasdiatric Society, June 4, 1890. He has kindly fur- 
nished me the following resume of this paper : 

" My methods of investigation were strictly in accord with those of the 
Koch school, and the results attained in the above cases correspond closely 
to those of the above authors in the adult subject. The twelve cases could 
be divided from a bacteriological standpoint into four groups. The first group 
includes those cases in which the examination of the pus of the empyema 

56 



882 LOCAL DISEASES. 

yielded either the streptococcus pyogenes or the staphylococcus pyogenes 
aureus. The etiology of this set of cases is still obscure. The exact source 
of these micro-organisms is still a matter of speculation. "Whether we agree 
with Weichselbaum, and assume that the empyemas may follow a pneu- 
monia (?), or that these organisms, being present in the subpleural tissues, 
may be enabled to become potent through such a predisposing agent as cold 
or a slight traumatism, the etiology for the present is veiled in doubt. The 
micro-organisms found are not characteristic. The second group of cases 
includes the empyemas of pneumonic character. They are those in which 
the diplococcus pneumoniae (Frankel and Weichselbaum) is found in the 
purulent exudate. In seven cases of the above series this micro-organism 
alone was found in the pus withdrawn from the chest. It was in uncontami- 
nated form, and when cultivated in pure culture and inoculated upon animals 
results were attained identical with those of Frankel and Weichselbaum. 
The isolated presence of such a virulent micro-organism in a pure state in 
the pus of an empyema must lead to the inevitable conclusion that a pneu- 
monia in the lung had preceded or complicated the empyema. In two cases 
of the above seven the pleural exudate, though at first quite serous in cha- 
racter, contained the diplococcus pneumoniae. These cases subsequently 
developed into well-marked empyemas. The pus in the empyemas also con- 
tained only the diplococcus of Frankel and Weichselbaum. 

" The third group includes those cases in which the processes are of a 
tubercular nature. There is only one case of this group to report — a boy 
aet. eight years. The tubercle bacilli were found in the pus by cover-glass 
stain only. Experiments upon animals have thus far proved negative. The 
pus in this case was contaminated with streptococcus pyogenes. The patient 
is still living at the time of writing, but the lung has not expanded on the 
affected side. There are no physical signs in this case of lung tuberculosis 
in the lung of the healthy or affected side of the chest. 

" The fourth group of empyemas includes those cases in which a focus of 
suppuration outside of the chest can with probability be fixed upon as a 
source of infection and as a direct cause of the empyema. In the above 
twelve cases only one, an infant aet. four months, could be classed in this 
group. For two weeks preceding the chest trouble the patient had suffered 
from a deep burrowing abscess of one foot. The study of the pus from the 
chest yielded a pure culture of streptococcus pyogenes. A pure culture of 
this injected into animals proved very virulent and fatal. The little patient 
died quickly, even in spite of operation for the relief of the empyema/' 

Anatomical Characters. — In the commencement of pleurisy the sub- 
pleural blood-vessels, lying in the connective tissue, and the capillaries of 
the pleura are engorged with blood, producing vascular points and arbor- 
escence, seen through a magnifying-glass of low power. Frequently in chil- 
dren, as in adults, minute extravasations of blood, resulting from extreme 
congestion, occur under the endothelial layer, scarcely perceived by the 
naked eye, but readily seen under the glass. Immediately exudation of 
liquid holding numerous cells begins in the connective tissue which sur- 
rounds the capillaries ; the pleura becomes dry and lustreless, while the pro- 
duction and exfoliation of its endothelial cells are greatly increased. These 
no longer present their normal appearance, but are swollen and granular in 
consequence of the inflammation. 

Immediately after these parenchymatous changes occur, serum, fibnn- 
ogenic substance, and leucocytes begin to exude upon the free surface of the 
pleura. The term fibrinogenic substance, instead of fibrin, is employed, 
because it is now believed that fibrin itself is not exuded, but a substance 
which becomes fibrin through the presence and action of certain agents with 



PLEURISY. 883 

which it comes in contact, among which may be mentioned air, red blood-cor- 
puscles, and even serum, from which fibrin has been precipitated (Virchow, 
Cornil. Eanvier, and others). 

In the exuded liquid, even if it have the appearance to the naked eye of 
ordinary serum, the microscope always reveals the presence of pus-cells or 
leucocytes and red blood-cells, however small their quantity may be. The 
minute rootlets of the lymphatic system, which are interspaces or lacunae in 
the subpleural connective tissue, and which here and there open by stomata 
upon the pleural surface, are clogged by inflammatory products and their 
walls swollen at an early stage (E. Wagner and others). In these lymphatic 
channels both pus-cells and coagulated fibrin are seen by the microscope. 
That pneumonia, whether catarrhal or croupous, seldom occurs in super- 
ficial parts of the lungs without causing inflammation of that portion of the 
pleura which covers the affected lobules is universally known ; but the 
reverse is also true, that pleurisy seldom occurs without causing inflamma- 
tion of the alveoli which are adjacent to the inflamed membrane. The pneu- 
monia thus caused is so superficial that it is very liable to be overlooked at 
the post-mortem examination in the presence of the graver lesions of the 
pleura ; but a knowledge of its occurrence is important in diagnosis, for, 
though it may have no greater depth than a line, it is sufficient to produce 
crepitant rales like those in ordinary pneumonia. Therefore, if we hear 
these rales, we may mistake the disease for pulmonary inflammation and 
overlook the pleurisy — an error not unusual in the treatment of' children. 
Trousseau, who surpassed most of his contemporaries as a clinical observer, 
wrote : " This sound, which is met with in the great majority of cases of 
pleurisy, is in fact a crepitant rale, and I have called it a crepitant rale of 
pleurisy. My interpretation is very simple. Just as we never have erysip- 
elas without engorgement of the cellular tissue, there cannot be erysipelas 
of the pleura or pleurisy without an irritative engorgement of the subpleural 
cellular tissue or of the peripheric pulmonary parenchyma. This fluxion 
naturally carries with it into the pulmonary vesicles a serous exudation. 
.... We also meet with a fine subcrepitant rale, which is very often heard 
quite at the beginning of pleurisy, and which likewise nearly always con- 
tinues for some weeks." More recent observers and writers fully agree with 
the statement of Trousseau, except that what he designates irritative engorge- 
ment, the microscope shows to be a true inflammation of the pulmonary 
alveoli. 

There are four constituents of every pleuritic exudation — to wit, serum, 
fibrin, red blood-corpuscles, and leucocytes or pus-cells ; which last are iden- 
tical in appearance with the white blood-corpuscles and the lymph-corpuscles, 
and the origin of which has been investigated by many microscopists. It is 
convenient to classify cases of pleuritis according to the quantity and rela- 
tive proportion of these constituents, as follows : 1st. The plastic, sometimes 
designated dry or adhesive ; 2d. The sero-fibrinous ; 3d. The purulent ; 4th. 
The hemorrhagic. 

1. Plastic Pleurisy. — In cases which pertain to this group the inflam- 
mation is chiefly parenchymatous, either no exudation occurring upon the 
free surface of the pleura, or if any, whether fibrin, pus, or serum, it is so 
slight that it possesses no clinical importance. The essential anatomical 
changes in this form of pleurisy, as regards the pleural surface, are rapid 
proliferation, retrogressive change or decay and exfoliation of the endothe- 
lial cells, and the sprouting out of granulations which develop into connec- 
tive tissue. In plastic pleurisy there is no compression of the lungs, and 
the pleural surfaces are separated from each other only by the granulations, 
which soon unite with those of the opposite surface. This form of pleurisy 



884 LOCAL DISEASES. 

is not infrequently latent in children, for at the autopsies of those who have 
died of various diseases we often observe bands of connective tissue uniting 
the opposite pleural surfaces, when the parents or nurses cannot recall to 
mind any sickness or symptoms such as pleurisy commonly causes. It is 
certain also that plastic pleurisy is often overlooked when not latent, the 
fever and other symptoms being attributed to causes quite distinct from 
the true one. The symptoms and physical signs are obviously less pro- 
nounced in this than in other forms of pleurisy. 

2. Sero-fibrinous Pleurisy. — This is the most frequent of all. It is the 
pleurisy which is usually thought to result from catching cold. The serum 
exudes from the capillaries of the inflamed pleura in very variable quantity in 
different cases, and the pleural surface is soon covered with a fibrinous layer. 
This may be a mere film or it may attain the thickness of half an inch or 
more. It is usually at first slightly attached, but afterward, from being 
blended with the granulations, it may be firmly adherent. In some cases it 
is quite compact, while in others it has a loose areolar texture, containing in 
its interstices serum and pus-cells, The fibrin is for the most part deposited 
on the pleura, but shreds and flakes of it also float in the serum. In the 
serum, as well as entangled in the fibrin, we find not only red blood-cells and 
leucocytes, but endothelial cells thrown off from the pleura, which, as well 
as those still adherent, are almost always in process of degeneration and 
decay. 

If a perpendicular section be made through the pleura, in this as well as 
in the other forms of pleurisy many newly-formed cells, the lymph-corpuscles, 
are observed in the meshes of the subpleural connective tissue, and, as we 
examine the section nearer to the surface of the pleura, these cells are seen 
to be aggregated in masses and held together by a structureless, homogeneous 
matrix. The lymph-corpuscles appear to be the active agents in the forma- 
tion of granulations. They are observed in various stages of transformation 
from the round to the spindle-shaped. The prolongations of the spindle- 
shaped cells unite with each other, so as to form the connective tissues, 
capillaries, and other elements of the granulating surface. That the 
endothelial cells take no part in the production of the new tissue is inferred 
from the fact that most of them present the appearance of retrogressive 
change and decay. The granulations, as they sprout out from the pleura, 
become intimately blended with the fibrinous exudation, and when the effused 
liquid is absorbed they unite with those of the opposite pleural surface, 
forming an organic union, by blood-vessels and nerves, between the lung and 
parietes, the lung and pericardium, or different lobes of the same lung, as the 
case may be. They pass in two or three weeks from embryonic to perfect 
tissue, vessels and nerves grow in them, and they possess henceforth all the 
properties of living tissues : they are able to absorb ; they are liable to 
inflammation and hemorrhage ; and may, in fine, participate in all the altera- 
tions of the organism of which they are a part (Jaccoud). 

3. Purulent Pleurisy. — Although, as stated above, pus-cells are always 
present in the pleuritic exudation, we designate the disease purulent pleurisy 
or empyema when the cells are so numerous as to render the liquid turbid. 
If there be cloudiness appreciable to the naked eye and due to the pus-cells, 
the case is regarded as one of this form of pleurisy. Purulent pleurisy is 
at first, in a large proportion of cases, sero-fibrinous, becoming purulent after 
some days or weeks — a fact readily ascertained by the use of the hypodermic 
syringe at different periods. In other instances the pleurisy is purulent from 
the first. Pleurisy is in family and in hospital practice more frequently 
purulent in children than in adults, and in ill-conditioned children than in 
those who are robust. It is therefore apt to be purulent in one who has had 



PLEURISY. 885 

an exhausting disease, as scarlet fever, and in the cachectic children who 
reside in or are brought to institutions for treatment. Thus, in the New York 
Foundling Asylum in 1879 an infant aged two months and three days became 
feverish, and had the expiratory moan and hurried respiration characteristic 
of pleurisy. On the fourth day Dr. Reynolds, who was in attendance, 
inserted the hypodermic syringe and filled it with thin pus. This was, 
apparently, a case of primary idiopathic empyema. Pleurisy is purulent 
when it is produced by the entrance of some irritating substance into the 
pleural cavity, as pus or decomposed lung-tissue. 

The production of pus in the pleural cavity is often surprisingly rapid, 
for, when many ounces have been removed by the aspirator, nearly the 
original quantity is sometimes restored within two or three days. As 
Frantzel says, it does not seem possible that so many pus-cells, which must 
surpass in numbers the aggregate of the white blood-corpuscles, could wan- 
der from the blood-vessel in so short a time, so that we must look for some 
other source of the immense production of leucocytes, in addition to that dis- 
covered by Cohnheim. A large part of the pus-cells is, in all probability, 
produced by rapid segmentation of the lymph-corpuscles. In two cases of 
purulent pleurisy, occurring in infancy, I found pus underlying the pleura 
near the hilus. without apparently any loss of integrity in the pleura, in such 
quantity that it was immediately recognized by the naked eye. Pus under 
the pleura, as well as in the pleural cavity, was apparently due to unusual 
violence in the inflammation and rapid production of leucocytes. 

4. Hemorrhagic Pleurisy. — This is not common. I recall but one case, 
a child, in whom the pleurisy occurred as a sequel of scarlet fever. The 
fluid several times removed by the aspirator had a deep reddish-brown color. 
I was apprehensive that the point of the aspirator, by wounding the granu- 
lations, had caused the hemorrhage which stained the pus removed at each 
subsequent operation. But with the care exercised and the great amount of 
blood-stained exudation, it seems almost certain that this was not the true 
explanation, and that it was a genuine case of hemorrhagic pleurisy. 

Hemorrhagic exudation in the pleurisy of children is sometimes due to 
purpura hasmorrhagica, being like the other hemorrhages a symptom of the 
general disease. In other cases it signalizes the commencement of a new 
inflammation in the vascular granulations of a previous pleurisy. Occurring 
under such circumstances, it is due to the increased fluxion in the numerous 
delicate capillaries of the granulations. Pleurisy due to cancerous or tuber- 
cular formations in or upon the pleura is sometimes hemorrhagic. Jaccoud 
says : " A sero-fibrinous or purulent exudation may be red by the transuda- 
tion of haematin, without true hemorrhage ; . . . . the red exudations which 
have been observed in scorbutus and marsh cachexia are really due to these 
pseudo-hemorrhages." In those cases in which there is true hemorrhage it is 
still uncertain whether rupture of the capillaries or a transudation ordinarily 
occurs, or whether the blood-cells may not escape in both modes. 

A liquid pleuritic exudation, whether sero-fibrinous or purulent, obviously 
produces an important mechanical effect from its location. In young children, 
especially those enfeebled by sickness, the expansive power of the lung is 
slight, so that it readily yields to pressure applied to its surface, and becomes 
more and more compressed as the liquid accumulates. Except when retained 
by adhesions, the lung is pressed toward the mediastinum, and at the same 
time carried forward and upward. Patients with pleurisy usually lie on the 
back and affected side, so that gravitation determines to a considerable extent 
in what part of the pleural cavity the liquid will collect. In the considerable 
number of post-mortem examinations which I have witnessed of children who 
perished from pleurisy, chiefly empyema, the lung was usually attached ante- 



886 



LOCAL DISEASES. 



riorly to the thorax from the mediastinum outward, as far as the eosto-chondral 
articulations, or farther, except in the lower part of the cavity, where there 
were no adhesions or adhesions only in the mediastinum. There were also 
attachments along the mediastinum, and attachments more or less firm on all 
sides, anteriorly, laterally, and posteriorly, in the upper part of the pleural 
cavity, toward which the lung was compressed. Many variations occur, 
depending on the amount of liquid and the extent of the adhesions ; but, 
judging from autopsies which I have seen, I would say that in the average 
in cases so severe that the question of operative interference arises, if we 
draw a line from the axilla downward and forward to the epigastrium, the 
lung is adherent to the thorax over the space anterior and internal to this 
line, while external and posterior to it the liquid separates the lung from the 
ribs. This fact is important, as indicating the proper point for puncturing 
the chest — namely, below the lower angle of the scapula and between the 
eighth and ninth ribs. One reason why the earlier performers of thoracen- 
tesis were so unsuccessful was that they selected the anterior wall of the 
chest as the point of operation. Now-a-days, however, no one would be jus- 
tified in performing thoracentesis unless he first employed the hypodermic 
syringe and removed fluid at the point which he selects for the puncture. 
The statistics of Mohr relating to lung displacement in empyema, chiefly 
statistics of adult cases, are somewhat different from my general recollection 
of cases occurring in infancy and childhood, as stated above. In 23 cases he 
found the lung free from adhesions and compressed against the vertebral 
column and the mediastinum ; in 13 cases the organ was compressed from 
below upward ; in 1 from above downward ; in 4 from within outward ; in 4 
from behind forward ; and in 4 from before backward. These variations 
depend on the adhesions which the lung happens to contract. Perhaps a 
point a little external to the perpendicular, passing through the angle of the 
scapula, is preferable for puncture, as I have known the lung to be adherent 
to the posterior wall of the chest near the mediastinum when the portion 
farther removed, say two inches from the median line, was separated by 
interposed liquid. 

Sometimes the liquid is collected in multilocular cavities formed by the 
connective tissue, and these frequently intercommunicate. Exceptionally in 
children, as in the adult cases observed by Mohr, when there has been a 
large and rapid liquid exudation or when the disease has been violent and 
of short duration, adhesions do not occur. 

On account of the great difference in the size of the pleural cavity at 
different ages during infancy and childhood, the amount of liquid which 
produces that degree of compression of the lung which materially impairs 
its function varies greatly. At the age of four months three ounces produce 
complete collapse of the lung, so that it resembles a fleshy mass (carnincation). 
The largest amount of liquid relatively to the size of the chest in any of the 
cases which I have observed was about one and a half pints in the left pleural 
cavity in an infant that died at the age of twenty-two months in September, 
1867. The heart lay chiefly to the right of the median line, and the diaphragm 
was convex toward the abdominal cavity. The case occurred in the almshouse 
on Blackwell's Island, and might in all probability have been relieved had 
attention been directed to it sufficiently early. 

Liquid in the left pleural cavity, when considerable, presses the heart 
toward the mediastinum, so that the apex-beat, instead of being a little 
internal to the linea mammalis, approaches the sternum. As the heart is 
carried to the right, the beat is felt under the lower end of the sternum, 
and with still greater increase in the effusion the pulsation is detected by the 
finger to the right of the sternum. If the exudation be on the right side, the 



PLEURISY. 887 

displacement of the heart toward the left is. for obvious reasons, less than 
the displacement toward the right in pleurisy of the left side. Much external 
pressure upon the heart embarrasses its movements and prevents proper filling 
of its cavities, while the action of the organ is accelerated so as to compensate 
the deficiency. Therefore, the pulse is quick and feeble. 

In one instance in my practice the lower extremities and the portion 
of the trunk below the thorax became oedematous from compression of the 
ascending vena cava, and writers allude to cases in which other vessels and 
ducts, as the thoracic, were compressed so as seriously to embarrass their 
functions. The patient with the oedema was a boy of about four years, 
with empyema of the left side. 

In large effusion the mediastinum is pressed against the healthy lung so 
as to diminish its transverse diameter, and Traube has shown that the effect 
of this is to increase the length of the lung or its vertical measurement. 
Consequently, as the lung on the healthy side extends lower than in the 
normal state, the convexity of the diaphragm on this side is diminished, as 
well as on the affected side, where it is depressed by the effusion. 

The pleura in protracted cases of empyema becomes much infiltrated, and, 
from the growth of connective tissue which blends with it, is thickened, some- 
times to the extent of one or two lines. A few months since, in removing the 
lungs from the body of a young infant that perished of empyema in the New 
York Foundling Asylum, a portion of the costal pleura, two or three inches 
in diameter, being adherent to the lungs, was detached from the ribs. It had 
a thickness of fully two lines and its free surface was rough. 

Occasionally the inflammation extends from the pleura to the pericar- 
dium, producing general pericarditis. I recall to mind 4 cases with this 
complication in which the diagnosis was verified by post-mortem examina- 
tions. All had empyema, 3 on the left, and 1 on the right side. Pericar- 
ditis, always a grave disease, is almost necessarily fatal when thus occurring 
as a complication of empyema. More rarely the inflammation extends from 
the pleura to the peritoneum. One such case occurred in my practice, the 
child dying of empyema on the right side, and at the autopsy we found the 
lesions of a localized diaphragmatic peritonitis of the right side, with a 
fibrinous exudation of small extent on the convex surface of the liver 
directly opposite to that on the diaphragm. We are indebted to Yon Reclr- 
linghausen for knowledge of the mode in which inflammation is propagated 
from the pleura to the peritoneum, and the same explanation probably 
applies to its propagation to the pericardium. In the serous covering of the 
diaphragm, pleural and peritoneal, minute stomata have been discovered 
which pertain to the lymphatic system. They open upon the surface of the 
diaphragm, and underneath in the substance of the diaphragm connect with 
lacunae or interspaces from which the minute lymphatic vessels originate. 
These stomata and lymphatic spaces, pervious in their normal state, are usually 
clogged, as has been stated above, by inflammatory products when the serous 
membrane is inflamed. Occasionally the inflammation traverses these lym- 
phatic channels from one surface to the other, from the pleura to the peri- 
toneum, thus causing by extension a circumscribed peritonitis. 

The changes which the inflammatory products undergo are the following : 
With the abatement of the inflammation the liquid portion begins to be 
absorbed, though absorption is much more tardy than in non-inflammatory 
effusions, since the absorbents are to a great extent covered and clogged by 
fibrin and pus. The serum is first absorbed, and the flocculi of fibrin sink 
into depending portions of the cavity or become attached to the fibrinous 
layers or the granulations upon the pleural surface. The pus-cells and the 
fibrin, whether in flocculi or layers, begin to undergo retrogressive change. 



888 LOCAL DISEASES. 

They become granular from fatty degeneration, liquefy, and are absorbed. 
Sometimes portions of these degenerated products which are not absorbed 
form inert caseous masses in recesses of the cavity or between the bands of 
connective tissue, where they remain unchanged for years. With few excep- 
tions, those who recover from an attack of pleurisy experience no subsequent 
ill-effect, though the bands and patches of connective tissue are permanent. 

Pus always possesses irritating properties. Decomposed and putrid pus 
(ichor) is very irritating. Empyemic pus, therefore, like pus in other situa- 
tions, now and then produces ulceration or necrosis of the pleural surface by 
which it is confined, and in consequence of its destructive action it sometimes 
establishes an outlet by which it escapes, with relief to the patient and cure 
of the disease. The chest-wall is thinnest anteriorly in the inframammary 
region, and at this point the pus, when it makes its way through the thoracic 
wall, usually points and discharges. The fistulous opening thus produced 
continues many months, until the pleural cavity is gradually obliterated by 
the adhesions and the patient recovers. 

By a similar destructive process in the pulmonary pleura pus occasionally 
escapes into the bronchioles and is expectorated. This mode of cure appears 
to be common in children, for my attention has not infrequently been called 
to the fact that children, during the progressive but slow convalescence from 
empyema, expectorated large quantities of muco-pus, although in some of 
the cases pus had been removed by the aspirator or trocar. Frantzel makes 
the remark — which is fully sustained by clinical experience in this country- 
that although an opening is made in the lung by the necrotic or ulcerative 
process, so that pus escapes into the bronchioles, air does not pass from them 
into the pleural cavity. Pyopneumothorax is very rare in the empyema of 
children, except as air is admitted in the operation of thoracentesis. 

As the liquid is absorbed the compressed lung ordinarily expands in pro- 
portion to the absorption, so that more and more air enters its alveoli. But 
frequently, in cases of long duration, the absorption proceeds faster than the 
expansion, so that the ribs on the affected side sink below their normal level. 
As a consequence, the intercostal spaces are narrowed, the shoulder is depressed, 
and the dorsal portion of the spinal column bends to accommodate the ribs, 
so as to be concave toward the affected side. It is very rarely that the 
deformity thus produced is permanent. Though the newly-formed bands and 
patches of connective tissue may so bind the lung that its return to the nor- 
mal state is tardy, yet with few exceptions the alveoli one after another open 
to admit air, and when full inflation is attained the symmetry of the chest is 
restored. But there are rare cases in which the newly-formed connective 
tissue is firm and unyielding almost as cartilage, and lime salts are some- 
times deposited in it, forming a calcareous plaque which invests the lung like 
a cuirass. An unexpanded lung with such a covering obviously can never 
afterward be fully inflated. I can recall to mind, however, only one case of 
permanent complete collapse or carnification of lung resulting from pleurisy. 
The inflammation, which was treated by the late Dr. Cammann, occurred in 
childhood, and several years afterward, when the patient reached womanhood, 
although the general health was good, there were physical signs of an 
unaerated lung and the consequent deformity (depressed shoulder and ribs 
and bent spinal column). Pleurisy with its granulations and retrogressive 
products affords one of the conditions in which tubercles are developed, so 
that we sometimes find, at the post-mortem examination of cases which have 
been protracted, " miliary tubercles in the pleura, while chronic phthisis and 
general tuberculosis are absent " (Delafield). 

From the intimate relation of the heart to the lungs this organ obviously 
suffers severely in every large pleuritic exudation. Total compression of a 



PLEUBISY. 889 

lung arrests one-half of the circulation through the pulmonary artery, except 
as the increased flow in the opposite lung serves for compensation. Hence in 
cases of large effusion which end fatally we commonly find the pulmonary 
artery and the right cavities of the heart distended with blood and clots, 
while the left cavities, having received a diminished quantity of blood, are 
probably empty. 

Symptoms. — As has been stated above, pleurisy in children is sometimes 
latent or attended by symptoms so mild as to attract little attention even 
when there has been general inflammation of the pleural surface with much 
effusion. Both primary and secondary pleurisy may present this form, 
latency being more frequent the younger the patient. In feeble, cachectic 
children, with blood thin and impoverished, pleuritic symptoms, as pain, 
dyspnoea, and fever, are less pronounced than in the robust, and hence 
latency is more common in the tenement-house population of the cities and 
in institutions than in the better walks of life. The following is a not infre- 
quent example of latency : A feeble infant, aged five months and twenty- 
eight days, died suddenly in the Nursery and Child's Hospital in December, 
1870. The attention of the resident physician had not been called to it, as 
it was not supposed to be sick, except that it was ill-nourished and its general 
condition bad. The nurse who had charge of the ward stated that it pre- 
sented no symptom of acute disease, unless a slight cough during the three 
or four days preceding its death. Percussion over the right side of the chest 
of the corpse gave a flat resonance, and at the autopsy the right lung was 
found compressed, nearly or quite destitute of air, and covered by a loose 
fibrinous layer three-fourths of an inch thick in places, and a moderate serous 
exudation. 

Ordinarily, acute idiopathic pleurisy in children begins quite abruptly, 
and with symptoms which attract attention from the first. Probably in most 
instances it is preceded by rigors or a chilly sensation, but this usually escapes 
notice, if it be present, in patients under the age of five or six years. Fever, 
fretfulness, and a physiognomy indicative of pain are the common initial 
symptoms. If the patient be an infant, the fretfulness closely resembles 
that produced by colic, for which I have on several occasions known it to 
be mistaken by the attending physician. 

The symptoms of pleurisy are twofold — namely, the constitutional, or 
such as are common to all inflammations, and the local, or those referable 
to the chest. Various observers have noted the position in which patients 
lie in bed as indicating the seat of the inflammation. It has been stated that 
adults, in the commencement of pleurisy, ordinarily obtain most relief with 
a decubitus on the sound side, but when effusion has occurred they lie on the 
affected side, unless there be marked dyspncea, which is most relieved by a 
semi-erect position, which allows greater descent of the diaphragm. I have 
not noticed that children with pleurisy prefer any fixed or uniform position, 
except there be marked dyspnoea, which may prompt them to elevate the 
shoulders. The patient in the acute stage is commonly quiet when he lies in 
the position which he selects, and if disturbed from it becomes more fretful, 
his cough more frequent, and his suffering apparently increased. 

In ordinary cases the temperature rises on the first day to 102° or 103°. 
If it be more elevated than this, there is usually a complication. The tem- 
perature begins to abate when the exudation has occurred. In suppurative 
pleurisy the fever is more protracted, often continuing for weeks or months, 
presenting, after the acute stage has passed, the characters of hectic fever, 
with morning abatement and evening recrudescence. In weakly and angeinic 
children, even when the pleurisy is pretty severe and most of the usual symp- 
toms are present, the temperature may be but slightly elevated. Thus in one 



890 LOCAL DISEASES. 

of the institutions with which I am connected, in a young infant whose fret- 
fulness was during the first twenty-four hours ascribed to colic, the axillary 
temperature during the first three days never rose above 100°. 

The pulse in the acute stage is usually between 100 and 130 per minute, 
but in young children who are restless it is often more frequent than this 
during the first week. It is accelerated as long as the temperature is elevated, 
but in sero-fibrinous pleuritis after exudation has occurred its frequency 
diminishes unless the heart be compressed. Compression and imperfect or 
partial filling of the cavities of the heart produce a feeble and rapid pulse. 
In empyema the pulse is accelerated as long as pus is confined in the pleural 
cavity, unless its quantity be small. 

Headache, usually frontal, is frequent during the febrile stage. Convul- 
sions, which occasionally occur in the beginning of pneumonia, are rare. 
Pain in the chest on the affected side is common, and is therefore a valuable 
diagnostic symptom, but it is often so slight as to be overlooked in infants 
and feeble children. It is increased by movements of the chest-walls, as in 
full inspiration, by coughing, and when pressure is made by the fingers in 
the examination. Its common seat is between the fifth and eighth ribs, exter- 
nal to the linea mammalis, but there are many cases in which the pain is 
referred to some other part, as the infraclavicular, mammary, inframammary, 
or even the scapular or infrascapular, region. Rarely, it is referred to the epi- 
gastric or umbilical region, or even, it is said, to some point upon the sound 
side of the thorax. This location of the pain at a point distant from the seat 
of the inflammation is attributable to the anastomosis of the intercostal nerves 
with those of the opposite side of the chest or with those which ramify in the 
abdominal walls. 

The pain of pleurisy, as it ordinarily occurs, has received different explana- 
tions. It has been attributed to tension of the pleura, to friction of the pleural 
surfaces on each other, and to extension of the inflammation to the neuri- 
lemma of the minute nervous branches of the pleura. All these causes 
apparently act in producing it, but the persistent pain in the first days of 
pleurisy, though increased by motion, is probably due in great part to that 
last mentioned. Pleuritic pain is sharp or stitch-like. It begins to abate in 
a few days, and in a large proportion of cases ceases by the fifth or sixth 
day, or is no longer noticed except in coughing or during sudden movement 
of the chest. 

The respiration is accelerated, as in all febrile diseases, but it is more rapid 
than in inflammatory ailments which do not involve the thoracic organs, on 
account of the pain experienced on full respiration. The patient instinctively 
avoids full inflation of the lungs, and the breathing is consequently rapid, to 
compensate for incompleteness of the inspiratory act. 

In ordinary attacks of pleurisy painful and hurried respiration is of short 
duration. It becomes easier and more natural toward the close of the first 
week. In subacute and chronic cases the rhythm and frequency of respira- 
tion differ but little from the normal. 

A cough, whatever the form of pleurisy, is one of the earliest symptoms. 
It is short, frequent, and dry, and in the most favorable cases begins to dimin- 
ish in the second week. A loose cough is due to accompanying bronchitis or 
broncho-pneumonia, or, at a late stage of the disease, to escape of pus from 
the pleural cavity into the bronchial tubes. 

Little need be said in regard to symptoms referable to the digestive appa- 
ratus. Vomiting is common on the first and second days. Thirst, loss of 
appetite, and consequent loss of flesh and strength, are uniformly present. 
In empyema, which from its nature is protracted, nutrition is always greatly 



PLEURISY. 891 

impaired. The surface presents an anasrnic appearance, the flesh is soft and 
flabby, and the emaciation is progressive till the pus is evacuated. 

Physical Signs. — In children above the age of three or four years the 
physical signs differ but little from those in adult cases, but under this age 
there are certain differences which the practitioner should know. We may, 
in the commencement of the attack, notice diminution in the movement of 
the chest-walls on the affected side, since the patient instinctively endeavors 
to repress respiration on that side in order to lessen the pain. In severe 
cases the epigastrium and hypochondria are sometimes depressed during 
inspiration (the so-called abdominal respiration), but this sign is less common 
and less marked than in severe bronchitis, and when present it may be largely 
due to accompanying bronchitis. After effusion has occurred and the pain 
has abated or is slight, the respiration is less accelerated than at first, and it 
may be nearly or quite normal. 

Inequality of the two sides produced by the liquid is more common in 
children of an advanced age than in those under the age of three or four 
years. In infants, even when there is a large liquid exudation, the bulging 
is often so slight that it is scarcely appreciable either by sight or measure- 
ment, and in not a few there is no apparent difference in the circumference 
of the healthy and affected sides. I have made measurements in infantile 
pleurisy during the stage of effusion, and been unable to convince myself 
that there was any difference, although other signs indicated the presence of 
an effusion which filled at least one-half the pleural cavity. I explain this 
fact in this way : The lungs of an infant, especially of one reduced by sick- 
ness, are very liable to a state of semi-collapse or partial inflation in their 
whole extent and of complete collapse of their thin borders, as of the tongue- 
like process of the left upper lobe, which lies over the pericardium, and of 
the margins of the lower lobes, which lie in the angle made by the thorax 
or diaphragm. This occurs in the weakly infant even when there is no ob- 
struction to the entrance of air, and the liability to it is greatly increased by 
external pressure applied to the lung, as from a pleuritic effusion, so that the 
lung recedes, becomes compressed, and unaerated before the ribs yield to the 
pressure. If the exudation cease as soon as the lung is collapsed, there is 
little or no outward displacement of the ribs and the intercostal spaces are 
not elevated. It is obviously very important to know this difference between 
infantile and adult cases, as it has a bearing upon the diagnosis between 
pleurisy with effusion and pneumonia. 

Palpation. — In adults and in children with strong voices, if the lung 
deprived of air, either by compression or an exudation within its alveoli, lie 
against the chest-wall, speaking or moaning produces a vibratory sensation 
which is communicated to the hand placed upon the chest. The fremitus is 
feeble or not appreciable when the voice is feeble. Therefore, in infants 
whose vocal cords are small, and particularly in infants reduced by sickness, 
this sign is ordinarily absent or so slight that it is detected with difficulty, 
while in older and robust children it is distinctly perceived. If the condition 
be otherwise favorable for the production of fremitus, but the lung be pressed 
away from the ribs by an intervening liquid, no vibration is felt when the 
patient speaks or cries. But if, in the same case, the fingers be removed to 
the suprascapular, axillary, infraclavicular, or mammary region, where the 
compressed lung comes in contact with the walls of the chest, fremitus may 
'be perceived. Palpation also enables us to ascertain the point of apex-beat 
of the heart, the variation of which from the normal size is one of the most 
conclusive proofs of a pleuritic effusion. 

Percussion. — In the first hours of pleurisy there is either no perceptible 
change in the percussion sound, or the resonance is slightly diminished from 



892 LOCAL DISEASES. 

the fact that inspiration on the affected side is resisted by the patient and the 
lung is only partially inflated. When exudation occurs, if there be a thin 
layer of liquid over the lung, the percussion sound is tympanitic. It has, 
therefore, this quality at an early stage in the inframammary, mammary, and 
perhaps infrascapular regions when the amount of liquid is small, and at a 
later stage, when the quantity of liquid is greater, the percussion sound over 
the lower part of the chest is dull, while that over the central or upper part 
is tympanitic. Entire filling of the pleural cavity with liquid, and total 
exclusion of air from the lung, give rise to a dull or flat percussion sound 
over every part from the apex to the base. It may be stated as a rule in the 
pleurisy of children that at a certain stage of the effusion percussion pro- 
duces a sound which is either decidedly tympanitic or which partakes of the 
tympanitic character. Skoda attributed the occurrence of tympanism to the 
fact that a lung still aerated vibrates better if surrounded by a thin layer of 
liquid, and consequently gives better resonance than when it lies against the 
chest-walls. 

When the exudation is so great that the lung is totally compressed and 
removed to a distance from the chest-walls, the finger in percussing experi- 
ences a sensation of solidity or resistance, and there is no longer any vibra- 
tion of the ribs. Consequently, the percussion sound is dull or flat, as over 
any solid body, differing from that in pneumonia, in which there is still some 
vibration of the chest-walls and the dulness is not absolute. In pleurisy, 
therefore, there is, according to the amount of exudation, either nearly the 
normal percussion sound, as at the beginning of the attack and in any stage 
of plastic pleurisy (pleuresie seche), or a zone of dull sound below and 
another of tympanitic sound above, or a zone of normal resonance above 
and one of dull resonance at the base, with an intervening one of tympan- 
ism ; or. finally, there is absolute dulness from the clavicle to the base of the 
chest. 

It very rarely happens in the child that the level of the fluid changes by 
changing the position, on account of the adhesions, so that this sign, described 
in the books as one of great importance in diagnosis, affords very little assist- 
ance to diagnosis in children. 

Auscultation. — In the beginning of pleurisy auscultation affords but slight 
information, except that the practised ear may detect a little diminution in 
the fulness of the respiratory act in the lung whose pleura is inflamed, and 
perhaps a slightly exaggerated respiration in the other lung. But after 
twelve or fifteen hours, when exudation begins to occur upon the pleural 
surface, we may hear the dry friction sound, which can be imitated by push- 
ing the finger strongly across the dry palm of the hand. It is only heard in 
occasional cases, since the physician may not make his visit at the proper 
time for hearing it or he does not apply the ear over the proper place. 
Frantzel says : " We shall scarcely ever fail to find the friction sound in 
recent pleuritis if we look for it early and diligently in some circumscribed 
spot." I do not think that this remark, however true it may be of adult 
cases, is entirely correct as regards children, for it is only in exceptional 
instances that it can be heard in them. It occurs both during inspiration 
and expiration, and it does not disappear after coughing. Being produced 
upon the surface of the lung, it seems near the ear of the auscultator. Per- 
haps it is not observed during several consecutive respirations, and then a 
deeper inspiration causes the pleural surfaces to glide upon each other, and 
it is detected. The friction sound as sometimes heard is well described by 
the term " scraping," and in other cases by the term " creaking," as was 
noticed by Hippocrates, who compared it to the creaking of leather. 

In some patients it is heard for a brief period, and does not recur, and it 



PLEUBISY. 893 

may be detected only during strong and deep respiration or in coughing. It 
disappears entirely when the accumulation of liquid prevents contact of the 
surfaces. After absorption of the liquid the friction sound may reappear, 
and in certain patients it is heard only at this time — to wit, in the third 
stage. 

An interesting and common sound heard on inspiration is the so-called 
crepitant rale of pleurisy, produced in the superficial alveoli. The remarks 
made by Trousseau upon it have been already given. As stated above, the 
inflammation extends from the pleura to the pulmonary vesicles which lie 
directly underneath, and as soon as exudation occurs within them the ana- 
tomical conditions are present in which the crepitant rale is produced, as in 
the ordinary form of pneumonia. This rale may obviously be heard before 
any effusion takes place upon the free surface of the pleura, and it continues 
until the alveoli are so compressed by the pleuritic exudation that they no 
longer admit air. 

The exudation in the pleural cavity changes the character of the respira- 
tory sound. A thin layer of liquid over the lung causes diminution in the 
force of the vesicular murmur, and soon an expiratory as well as an inspira- 
tory sound begins to be heard. This modified vesicular murmur is weak, 
and more distant from the ear than the respiratory sound of health. When 
the exudation is sufficient to close the alveoli, while the air still traverses the 
medium-sized bronchial tubes, we notice a tubular or bronchial bruit. If the 
small and medium-sized tubes are compressed while the air enters the large 
tubes, the respiratory bruit may be amphoric. Total absence of respiratory 
sound results from complete collapse of the alveoli and consequent exclusion 
of air from them, and arrest of the movements of the air in the tubes of the 
affected side. Jaccoud says : " Regarded as a sign of the quantity of the 
effusion, the modifications of the respiratory bruit and of the respiration may 
then be arranged in an increasing series, as follows : diminution of the vesic- 
ular murmur ; feeble respiration (souffle doux) ; no sound and feeble respira- 
tion ; bronchial respiration ; no sound and bronchial respiration ; no sound 
and cavernous respiration ; general absence of sound {silence general). The 
replacement of an inferior term of the series by a superior term implies an 
augmentation in the quantity of liquid, and in general the passage of a 
superior term to an inferior term denotes a diminution of the effusion." But 
this statement relating to the effect upon the auscultatory sounds of the 
increase and decrease of the liquid must be modified as regards patients 
under the age of five years. In such patients it is rare, however great the 
effusion, that respiration is not heard when the ear is placed over the liquid. 
This is due to the small size of the pleural cavity, and the consequent ready 
transmission of sound from the centre of the thorax to its periphery. Accord- 
ing to the amount of exudation and the degree of compression, the respira- 
tory sound is a faint and distant vesicular, or broncho-vesicular, or bronchial 
murmur, and its character is found to vary from one to the other of these 
sounds as we apply the ear over different parts of the chest. 

When the inflammation is active and the exudation occurs rapidly, bron- 
chial respiration may be heard as early as the second or third day, or even by 
the close of the first day, in the infrascapular region. If, on the other hand, 
the inflammation be chiefly plastic or the exudation of liquid be slow and its 
quantity small, the respiratory murmur may be vesicular, though faint and 
distant, during the whole course of the attack. Sometimes when the mur- 
mur is vesicular in the greater part of the lung, broncho-vesicular or bron- 
chial respiration is heard over a limited area, where the effusion happens to 
be sufficient to produce requisite compression of the lung. 

The voice of the patient when auscultated over the affected side has a 



894 LOCAL DISEASES. 

character which corresponds with and varies according to the respiratory 
murmur. Vocal resonance is feeble or absent if" the respiratory murmur be 
vesicular. If it be bronchial, the auscultated voice is more distinct, having 
the character known as bronchophony, or when there is a moderate quantity 
of liquid over the lung, so that this organ vibrates, it may have that modifi- 
cation of bronchophony known as aegophony. Occasionally we can hear the 
voice as a confused and distant sound when the quantity of liquid is so 
great that respiration is inaudible. The signs derived from the auscultated 
voice are not, as is well known, pathognomonic of liquid effusion. Bronchoph- 
ony is more common and distinct in pneumonic or tubercular solidification 
of lung than in pleurisy, and even aegophony may be produced without the 
presence of a liquid by " pleural membranes realizing certain physical con- 
ditions " (Jaccoud). But since the auscultated voice is weaker in children 
than in adults, we often do not hear it in infants and ill-conditioned children, 
even when the anatomical conditions as regard the lungs and pleural cavity 
are favorable to its transmission. 

In children, as in adults, bronchial rales are common in pleurisy, dry or 
moist ; coarse when produced in the larger tubes, or fine when occurring in 
the finer tubes. 

Diagnosis. — Ordinarily, a careful observance of the history, symptoms, 
and physical signs enables the physician to make a positive diagnosis. Obscure 
or doubtful cases occur chiefly in infancy. Circumscribed pleurisy or pleurisy 
attended with little or no liquid exudation is obviously likely to be overlooked 
and its symptoms mistaken for those of another disease. 

Pleurisy before the stage of exudation may be mistaken for pneumonia, 
since the prominent symptoms in the commencement of the two diseases are 
similar. But in pleurisy there are commonly greater acceleration of pulse 
and respiration, greater suffering as evinced by the features, greater tender- 
ness on percussion or on pressing the chest-wall, and a more decided expira- 
tory moan, while the patient probably endeavors to repress respiration on the 
affected side, so that inflation of the lungs is partial and shallow. It will aid 
in the diagnosis to recollect that in children under the age of five years acute 
pneumonia is in most instances catarrhal, and not croupous, and is preceded 
and accompanied by severe bronchitis, being due to downward extension of 
the inflammation from the bronchial tubes. It therefore does not begin with 
the abruptness of pleurisy. 

Pleurisy with effusion may be mistaken for pneumonia in the stage of 
solidification, for hydrothorax, or. on the left side, for pericardial effusion, or 
vice versa. But the percussion sound over a pleuritic exudation is either 
tympanitic or flat, while over a lung solidified by inflammation it has some 
resonance, though dull. There is also a sensation of greater resistance and 
solidity in percussing over a pleuritic exudation than over an inflamed lung. 
Moreover, the respiratory murmur, whether vesicular, broncho-vesicular, or 
bronchial, is more distant and less distinct to the ear of the auscultator 
when applied over a liquid than over a solidified lung. 

A pleuritic exudation, unless slight, also changes the apex-beat of the 
heart, pressing it toward the median line in left pleurisy, and away from 
the median line in right pleurisy, as has been stated above — a change not 
observed in pneumonia. Bulging of the intercostal spaces, expansion of 
the chest-walls, change in height of the fluid by change in the position of 
the child — important signs in the diagnosis of adult pleurisy — are, as we 
have seen, commonly absent in young children, even when there is abundant 
liquid effusion, but they are sometimes observed in children of a more 
advanced age. Bronchophony and vocal fremitus, signs of pneumonic solid- 
ification, are absent or so feeble in the pneumonia of young children that 



PLEURISY. 895 

their absence cannot be regarded as indicative of the presence of pleuritic 
effusion, except in children over the age of four or five years. Moreover, 
these signs, when present, do not necessarily indicate pneumonia, for if in 
pleuritic effusion the ear or hand be placed over a part of the chest where 
adhesions have united the lung to the ribs, and the child be of such an age 
that the vocal cords have sufficient vibration, both bronchophony and the frem- 
itus may be perceived. The absence or presence, therefore, of vocal fremitus 
and bronchophony affords only limited assistance in the differential diagnosis 
of pleurisy and pneumonia in young children. In those of an advanced 
age. whose vocal cords have greater vibration, it aids in the discrimination 
of doubtful cases, especially if the examination be made in the infrascap- 
ular region, which corresponds with the location of the liquid if any be 
present. 

A pleuritic effusion is distinguished from hydrothorax by the fact that 
the latter is usually bilateral and of slow increase, without symptoms refer- 
able to the chest, except when there is considerable effusion, which causes 
more or less dyspnoea. Pleurisy, unlike hydrothorax, causes fever and other 
constitutional symptoms, and also a cough, pain in the chest, and early 
embarrassment of respiration. Moreover, hydrothorax seldom occurs, except 
from cardiac or renal disease or scarlet fever. 

A greatly distended pericardial sac simulates in some degree a pleuritic 
effusion on the left side, but the absence of symptoms which pertain to 
pleurisy, as the cough, stitch-like pain in the chest, the localization or greater 
distinctness of the dull sound on percussion in the cardiac region, absence or 
feebleness of the apex-beat, and indistinctness or distance of the heart-sounds, 
will preserve the observant physician from error of diagnosis. 

Prognosis. — In mild cases attended with little exudation the inflammation 
soon begins to abate, and by the close of the second week the symptoms have 
nearly disappeared. In plastic and sero-fibrinous pleurisies recovery may be 
confidently expected, unless there be some grave complication, or perchance 
syncope should occur from large and rapid effusion. A large effusion, what- 
ever its character, especially if located on the left side, often causes such a 
twist in the great vessels within the thorax as seriously to retard the circula- 
tion of blood and endanger life. In effusions of the left side the heart is often 
carried so far toward the right that the ascending vena cava, where it emerges 
from the central tendon of the diaphragm, is bent at an angle so as seriously 
to obstruct the return of blood from the lower half of the body, and conse- 
quently a reduced quantity of blood reaches the right cavities and the 
pulmonary artery. The result is a diminished flow of blood in the systemic 
circulation, with anaemia of important organs, as the brain. The great arteries 
connected with the heart are also more or less bent in cases attended by dis- 
placement of this organ. In effusions on the right side the right auricle and 
ventricle sometimes do not expand to the normal extent during the diastole, 
on account of the pressure of the liquid, and the result is similar to that 
in effusions on the left side as regards obstructed circulation and anaemia of 
important organs. Therefore, patients with large pleuritic effusions, whether 
left or right, are liable to sudden fainting and even to fatal syncope. For- 
tunately, with our present improved methods of thoracentesis children need 
not perish in this way if the operation be resorted to at the proper moment. 
There is another danger. When, in consequence of the exudation, the lung is 
so compressed that its function is nearly or quite lost, the sound lung obviously 
receives an augmented supply of blood. It is therefore very liable to sudden 
congestions and transudation of serum (oedema). If this occur, the dyspnoea 
is augmented and the condition is one of utmost peril. Death may result 
from this state. 



896 LOCAL DISEASES. 

The prognosis obviously varies according to the cause of the inflammation 
and the quantity and nature of the exudation. Idiopathic pleurisies do better, 
as a rule, than those which occur as a complication or sequel of some other 
disease. Absorption is more rapid in the beginning of convalescence, when 
the fluid is thin, than at a later period, when it has greater consistence. 
Fibrin, whether flocculent or laminated, is necessarily slowly absorbed, first 
undergoing fatty degeneration and liquefaction. Empyema, if not relieved 
by operative measures, continues many months ; even after pus is let out 
convalescence is slow. In the very considerable number of empyemic cases 
which have from time to time been brought to the class of children's diseases 
in the Bureau for the Relief of the Out-door Poor the histories commonly 
showed that the disease had continued from three to six months, with pro- 
gressive loss of flesh and strength. Nevertheless, after proper evacuation 
of the pus and the establishment of a fistulous opening the majority have 
gradually recovered, death in the unfavorable cases being commonly due 
to extreme prostration, with perhaps fatal organic changes, as amyloid 
degeneration and tuberculosis. 

Secondary pleurisy occurring in a reduced state of the system, as after 
scarlet fever, and pleurisy complicated by a grave disease, as pericarditis or 
pneumonia, are always dangerous to life. 

It is the common belief that pleuritic effusions involve greater danger on 
the left than on the right side, from the fact that the exudation in the left 
pleural cavity produces more immediate and direct pressure on the heart and 
causes a greater twist in the vessels than is produced by that in the right 
cavity, but Leichtenstern 1 states that in 52 cases of sudden death from 
pleuritic effusions, 31 were right and 20 left pleurisies. The walls of the 
cavities of the heart, upon which the liquid in the right pleural cavity directly 
presses are thinner, and therefore more yielding, than the walls of the left 
cavities. The records of the cases collected by Leichtenstern show that 
sudden death sometimes results from extensive and far-reaching thrombi in 
the right cavities of the heart and in the superior vena cava, or from emboli 
detached from the thrombi and intercepted in the pulmonary artery. In grave 
cases attended by large effusion sudden death sometimes occurs after some 
exertion on the part of the patient, as after vomiting, severe coughing, or 
hurried rising to the erect position or lifting a heavy weight. It is believed 
that under such circumstances there is a retarded flow of blood through the 
lungs and into the left cavities of the heart and the aorta, so that sudden 
and fatal anaemia of the brain is produced. 

As already stated, death may occur in protracted cases from amyloid 
degeneration of important organs, as the kidneys and liver. This can some- 
times be detected by enlargement of liver and spleen and the occurrence of 
albuminuria. 

It is evident that the prognosis varies greatly according to the degree 
of dyscrasia. In profound blood-poisoning, whether scarlatinous, uraemic, 
or septicemic, pleurisy is always grave. Septic pleurisy, which occurs for 
the most part in new-born infants during epidemics of puerperal fever, is 
especially so. When it has continued a few hours the pinched features and 
rapid sinking show that we have to deal with something more than an 
ordinary attack. 2 

1 Deutsches Archiv fur kiln. Med. , Band iv. 

2 The following case, which occurred in my practice during the epidemic of puer- 
peral fever in 1881, may be adduced as an example : Mrs. D , a primipara, was 

delivered by the forceps, after a tedious labor, at 9 p. m. , April 6th. On the following 
morning her temperature, without the occurrence of a chill, had risen to 105^°, and her 
pulse varied between 125 and 134. She was in a critical state for several days with a 



PLEURISY. 897 

Pleurisy is also very severe, and ordinarily fatal, when it is caused by the 
entrance of some pathological product into the pleural cavity, as pus or decay- 
ing lung-substance. 

" Treatment. — It will be proper, in considering the treatment, to describe 
that which is appropriate for each of the three stages into which writers 
have for convenience divided pleurisy : First, the stage preceding effusion ; 
secondly, that of effusion ; and thirdly, that of absorption and convalescence. 
In the beginning of the inflammation appropriate measures should be promptly 
employed for the purpose of reducing the inflammation and preventing or 
diminishing, so far as possible, the exudation that soon follows. The abstrac- 
tion of blood is now properly discarded in the treatment of most inflammations 
of infancy and childhood, but in certain cases of pleurisy occurring in robust 
children over the age of four or five, or even three years, the early and judi- 
cious employment of one or two leeches diminishes the pain and temperature, 
and apparently also, to a certain extent, the inflammation. But it may be 
stated as a rule that the loss of blood is not only not required, but is inju- 
rious, in all secondary pleurisies and in the primary form after exudation has 
occurred. It is injurious in all forms of pleurisy in pallid and cachectic 
children, and therefore in a large proportion of the cases occurring in the 
tenement-houses and institutions of the cities. The flow of blood from the 
bites if leeches are employed should ordinarily be arrested after two or three 
hours, but if slight it may continue longer in vigorous children of eight or 
ten years. 

At the first visit of the physician an emollient and slightly irritating 

temperature varying between 103° and 105J°, and without any local symptoms either 
of metritis or cellulitis, but finally recovered. The baby, healthy and vigorous at birth, 
had been allowed to obtain what nutriment it could from the breast, but the nurse 
remarked that she "never saw a child sleep so much," and I gave very little attention 
to it, as my time was devoted wholly to the mother. On the 10th, when four days old, 
its sleepiness ceased, and it became constantly fretful, as from colic, and it refused to 
draw the nipple. Early in the morning of the 11th I was summoned to it, and was 
astonished at its altered appearance, its shrunken features, and its evidently dying state. 
Percussion upon the right side gave a fiat resonance from the clavicle to the diaphragm, 
and there was some meteorism in the abdomen. The thermometer introduced into the 
rectum showed no elevation of temperature, and no unusual heat of surface or cough had 
been noticed by the nurse. By active stimulation the infant lived till the middle of the 
afternoon. The autopsy revealed a sero- fibrinous exudation filling the right pleural 
cavity, producing complete carnifi cation of the lung, so that it resembled that of the 
foetal state, and soft patches or flakes of fibrin upon the lungs. By an oversight the 
peritoneum was not examined. Cases like this, of pleuritis in the new-born, produced, 
it is thought, by the wandering micrococci of the septic state, occur chiefly during epi- 
demics of childbed fever. Some years ago I saw a new-born infant in one of the insti- 
tutions, whose mother had puerperal fever, die in a similar manner, and the autopsy 
showed that the cause was peritonitis. The following example from Trousseau' s clinical 
lecture on erysipelas of new-born infants will aid in understanding such cases. Speaking 
of Dr. P. Lorain, he says : " During the epidemic at the Maternite, where this able and 
laborious observer was resident pupil, he collected the information of which the follow- 
ing is a summary : Of 106 stillborn infants, 10 were found to have died from peritonitis, 
and 3 of the mothers of these 10 infants were carried off by puerperal fever after delivery. 
Of 193 infants born alive, 50 died of the very same affections which proved fatal to the 
lying-in women. The most frequent causes of death were peritonitis, numerous abscesses, 
purulent infection, phlegmonous swellings, erysipelas, gangrene of the limbs, putrid 
infection, or some other remarkable septic condition." .... " Mother and child, then, 
are subject to the same morbific influence." Farther on Trousseau says of the infant 
affected by this puerperal poison : "It will cry incessantly from pain. A state of rest- 
lessness will be succeeded by collapse, which will close the scene on the fifth, sixth, or 
seventh day. On examining the body after death pus will be found in the cellular 
tissue, sometimes suppurative pleurisy, more frequently phlebitis of the umbilical vein 
or of the vena porta, or peritonitis." An interesting incidental fact shown by these 
statistics is that the cause of this puerperal disease of the new-born is sometimes operative 
in the fcetal state. 

57 



898 LOCAL DISEASES. 

poultice should be ordered, enveloping the entire chest, to be constantly 
worn, except as it is temporarily removed during the application of the leech 
and the subsequent flow of blood. The poultice should be so mildly irritat- 
ing that it causes constant redness of the skin without pain, and it should 
not be removed except when a fresh poultice is prepared to replace it. Thus 
employed, it produces constant dilatation of the capillaries of the skin, and by 
the fluxion caused diminishes the engorgement of the capillaries of the costal 
pleura. A poultice of common mustard, with flaxseed in powder, one part to 
sixteen, between two pieces of muslin, and so wet that it moistens the hand 
in holding it, produces this effect. Applied morning and evening, it can be 
constantly worn without complaint of pain produced by its irritating action. 
For infants under the age of eight months I prefer the use of plain flaxseed, 
with camphorated oil smeared upon its under surface. The oil may be 
applied several times daily, while the morning and evening application of the 
poultice is sufficient. Spongiopilin or compresses of flannel wrung out of 
hot water and covered with oil-silk meet the indication, and possess the 
advantage of being lighter and cleaner and more readily applied than the 
poultice. Redness may be produced by applying under the spongiopilin a 
single thickness of muslin soaked with camphorated oil, or for children of a 
more advanced age with camphorated oil and one-fourth part of turpentine. 

Vesication, formerly much employed, has properly nearly fallen into dis- 
use in the treatment of the pleurisy of children. While it is liable to 
increase the suffering, it has apparently no tendency to diminish the inflam- 
mation in whichever stage employed, and there is no certainty that it stimu- 
lates the absorbents and expedites the removal of the liquid, according to the 
old theory. A case is reported in the practice of one of the New York phy- 
sicians in which a blister had been applied when the inflammation was still 
active, and at the autopsy the portion of the costal pleura which lay directly 
underneath the surface that had been vesicated was covered by a thicker 
fibrinous exudation than that upon the contiguous surface. The increased 
afilux of blood caused by the blister had, to appearance, extended to the 
costal pleura and increased the pleurisy. The application of cold bandages 
around the chest, which is recommended by some, seems to aggravate the 
cough in certain patients, and does not ordinarily give the relief of moist and 
warm applications. 

Internal Remedies. — The indications are to employ such medicines as 
diminish the frequent action of the heart, and thus retard in a measure the 
flow of blood to the pleura, and such as diminish the pain and frequency of 
the cough, which by increasing the friction of the pleural surfaces tends to 
increase the inflammation. For robust children over the age of three years 
in the first stage of primary pleurisy the tincture of aconite may be pre- 
scribed, half a drop for a patient of three years, and one drop for one of six 
years, every third hour for two or three days or until the required effect be 
produced upon the pulse, when it should be discontinued. It is, as a rule, 
too depressing for younger patients. Digitalis is a better and safer remedy 
for children under the age of three years for all secondary pleurisies and for 
all cachectic cases. Benefit results from continuing the use of digitalis in 
the stage of exudation, when aconite would be inadmissible. A child of two 
years can take two drops of the officinal tincture, and one of five years four 
drops, every two or three hours. 

Antipyrine is an effectual antipyretic. One or two doses reduce tempera- 
ture two or three degrees. It therefore promises to be a useful remedy in 
the first stage of pleuritis as well as in other acute diseases, when the tem- 
perature is so high as to involve danger. It is not a tonic, and it seems to 
impair the digestive function. It is therefore most useful in those diseases 



PLEURISY. 899 

which are not attended by any marked prostration, but in which the fever, 
from its intensity, exhausts the strength. If, therefore, in the commence- 
ment of pleurisy the temperature rises above 103°, it may properly be pre- 
scribed in doses of four grains to a child of five years, and be repeated, if 
necessary, in three hours. It is soluble in water, and it may be employed 
as an enema if the stomach be irritable. Phenacetin or antifebrin may be 
employed as a substitute for antipyrine. 

The use of quinia is suggested, since it is an antipyretic and tonic, but in 
my practice it has been much less useful in pleurisy than in pneumonia. 
This agent, in whatever form given, does not appear to exert any notable 
controlling effect either on the fever or gravity of pleurisy. Nevertheless, I 
have often employed it, especially in secondary pleurisies, with or without 
digitalis, and it probably does some good as a tonic. The salts of quinia, as 
ordinarily given in solution to young children, are frequently vomited. When 
vomited, a soluble salt, as the bisulphate, may be given as a suppository, or 
Squibb's oleate of quinia may be employed by inunction. I should, however, 
add that, though I have used inunctions of the oleate in pleurisy during the 
last year, ten grains of the alkaloid at a time, I have not seen any marked 
beneficial effect. To meet the second indication in the treatment of the first 
stage — namely, to relieve the pain and restlessness and to diminish the cough, 
so that there is less friction of the pleural surfaces — our chief reliance must 
be on hyoscyamus or one of the opiate preparations. The following formulae 
will be found useful : 

R. Tinct. opii deodorat., 
Tinct. digitalis, 
Syr. pruni Virginian!, 
A quae, ^ iss. — Misce . 

Dose : One teaspoonful (one drachm) every three hours for an infant of eighteen 
months. The tincture of hyoscyamus may be employed in place of the opiate 
in double the dose. 

For a child of three years : 

R. Tinct. ipecac, comp. 

(Squibb's liquid Dover's powder), 
Tinct. digitalis, da. gtt. xxxij ; 

Syr. pruni Virginiani, ^ij. — Misce. 

Dose : One teaspoonful every two or three hours. 

For a robust child of eight years with primary pleurisy : 

R. Morph. sulphat., gr. j ; 

Tine. rad. aconit, gtt. xx ; 

Syr. pruni Virginiani, ^iiss. — Misce. 
Dose : One teaspoonful every three hours. 

The diet in the first stage should consist of milk and farinaceous food, 
given liberally. The meat teas or the expressed juice of meat may be added, 
and in secondary pleurisies, as after scarlet fever, it is often proper to give a 
moderate amount of alcoholic stimulants from the first. 

Second Stage. — Measures employed in the first stage have been designed 
to diminish the inflammation and relieve suffering. The duty of the physician 
in the treatment of the second stage is chiefly to aid in the removal of the 
inflammatory product, and prevent, so far as possible, its further formation. 
If this be sero-fibrinous and its quantity be small, so as to fill only the lower 
portion of the cavity, little aid may be needed from therapeutics ; but a larger 
effusion, compressing the lung and displacing the heart, requires medicinal 




900 LOCAL DISEASES. 

and often surgical measures. The recommendations of Niemeyer, that the 
patient's food contain little liquid and that his drinks be restricted as a means 
of increasing absorption from the pleural surface, is not applicable to young 
children, whose diet must of necessity be largely liquid, and that of infants 
chiefly milk. 

Attempts to stimulate the absorbents by external treatment of the chest 
are of doubtful efficacy, whether by the application of small blisters, can- 
tharidal collodion, the iodine ointment or tincture, or a stimulating liniment. 
The common practice of treating glandular swellings by iodine applications 
suggests their use for pleuritic effusions, and of the agents employed locally 
to hasten absorption they are probably the best, but they should not be used 
so often or in such quantity as to cause pain or restlessness from their irri- 
tating effect. The following ointment may be used : 

R. Potas. iodidi, gij ; 

Lanolin, Jij . — Misce. 

To be rubbed freely over the side of the chest which is the seat of the sero-nbrin- 
ous exudation three or four times daily. 

It is an established principle in therapeutics that the removal of a serous 
liquid in either of the larger cavities of the body is hastened by such rem- 
edies as produce an abundant liquid secretion or transudation from any of the 
organs or surfaces. Hence in the treatment of pleuritic effusions those med- 
icines which act on the skin, causing diaphoresis, upon the intestines, causing 
watery stools, and upon the kidneys, causing diuresis, are at once suggested 
as most likely to be efficacious. But sudorifics, though useful for dropsies 
having a renal origin, have not been much used of late years for the removal 
of exudations in the pleural cavity, experience having shown that they are 
inadequate for this purpose. Recently, however, the discovery of a very 
active agent of this class, jaborandi, has revived in a measure the sudorific 
treatment of the second stage, so that in the National Dispensatory of Stille 
and Maisch this diaphoretic is one of the recommended remedies. But the 
heart, crippled in its action by the pressure of the liquid, badly tolerates 
agents of a depressing nature, and jaborandi, or its active principle pilocarpine, 
exerts a weakening effect on this organ. It therefore should be used with 
caution in this disease. It is probably best in most instances not to employ 
it, inasmuch as we possess other and efficient remedies. 

The fact that sero-fibrinous exudations have been known to diminish rap- 
idly during attacks of diarrhoea suggests the use of purgatives ; but, although 
an open state of the bowels, as two or three daily stools, aids in absorption, 
free purgation is badly borne by young or feeble children, as it reduces the 
strength, and therefore is not to be recommended as a therapeutic measure. 
Moreover, there is not the need of employing severe or exhausting medicines 
for the removal of the liquid which existed in former times, since we are able 
to accomplish this quickly, easily, and safely by the excellent aspirating 
instruments now in common use. 

Diuretics, on the other hand, are apparently more useful, while they are 
less exhausting, than sudorifics or cathartics. Digitalis, combined with the 
citrate or acetate of potassium, has stood the test of experience, and is now 
more widely used than any other agent of this class. Being both a diuretic 
and heart-tonic, it possesses properties which render it especially serviceable 
in the treatment of pleuritic effusions. The following is a useful prescription 
for a child of five years : 

R. Potassii acetatis, £ij ; 

Infus. digitalis, ^iij. — Misce. 

Give one teaspoonful every three hours. 



PLEURISY. 901 

It is a matter of observation that absorption occurs more rapidly, and a 
sero-fibrinous is less likely to become a purulent effusion, if the bodily con- 
dition be good. Hence tonics, especially the bitter vegetables, are sometimes 
useful, and a diuretic in combination with a tonic, as the acetate of potassium 
in decoction of cinchona, may often be prescribed with advantage. 

Still, however judicious the treatment, hygienic and medicinal, many 
cases require surgical interference, and the number of such is larger in the 
city than in the country, and in tenement-houses than in the better walks of 
life, since the cachexia so common in city children increases the liability to 
purulent exudations. 

Thoracentesis. — The indications for the operation are the following : 

1st. Dyspnoea due to the presence of the liquid, whether it be sero- 
fibrinous, purulent, or hemorrhagic. Usually when dyspnoea occurs the 
pleural cavity is full, and if there be parenchymatous disease of either lung, 
a moderate quantity of liquid may cause such embarrassment of respiration 
that thoracentesis is indicated. 

2d. A flat percussion sound over the entire affected side, with displace- 
ment of the heart, even if there be no present dyspnoea, is also an indication 
for the operation, for dyspnoea may occur suddenly with other alarming symp- 
toms between the visits of the physician. Moreover, experience has shown 
that absorption from a distended pleural cavity is very tardy, in consequence 
of compression of the absorbents, whereas if a portion of the liquid be 
removed absorption of the remainder is more rapid. The patient with full 
pleural cavity and lung totally compressed lies on the affected side, and is 
usually uncomfortable in any other position, and the withdrawal of a portion 
of the liquid — as, for example, one half — the operation being discontinued 
when the patient begins to cough or evince distress, produces no ill effect and 
increases the comfort. 

3d. A moderate effusion, without material decrease in quantity after some 
weeks of observation, also indicates the need of surgical interference, since 
long compression of a lung involves risks. There is danger that catarrhal 
ending in cheesy pneumonia and tubercles may occur in a lung whose func- 
tion is long suspended ; besides, the longer compression has existed the more 
tardy, difficult, and incomplete will be the inflation when the liquid is removed, 
on account of the altered state of the alveoli and the presence of fibrinous 
bands over the lung. Thus, in a case recently under observation only partial 
inflation of the lung occurred after letting out the liquid, so that the ribs and 
shoulder on the affected side are permanently depressed and unequivocal 
symptoms of tuberculosis are now present. 

4th. If the inflammation extend to the pericardium, so as to cripple the 
heart's action, or if there be any serious pre-existing heart disease, the liquid, 
even in moderate quantity, may by pressure so embarrass and retard the 
heart's action that its cavities are not properly filled, so that passive conges- 
tion of certain organs and dangerous anaemia of others, especially of the 
brain, may result. Under such circumstances an early performance of tho- 
racentesis is indicated. 

5th. Empyema. — The presence of pus in the pleural cavity affords in itself, 
in a large proportion of cases, sufficient indication of the need of thoracente- 
sis. In recent cases with only moderate constitutional disturbance and embar- 
rassment of respiration, if we ascertain by the hypodermic syringe that the 
liquid is only slightly clouded by leucocytes, surgical interference may be 
postponed while the acute inflammation is treated. Thus, in case of an 
infant of two months thin pus was withdrawn on the fourth day of acute 
pleuritis, and, although thoracentesis was early performed, it appeared prob- 
able, from the subsequent course of the case, that it would have been as well 



902 LOCAL DISEASES. 

had the operation been deferred. If spontaneous evacuations of pus have 
occurred through one of the intercostal spaces, producing a fistula from 
which there is a daily oozing, or if it be probable, from the symptoms and 
signs, that pus is escaping from the pleural cavity into a bronchial tube, and 
is being gradually expectorated — a mode of cure which is not infrequent in 
children — thoracentesis may be deferred. In the case of an infant aged six 
months recently under treatment for empyema of the left side we removed 
four ounces of pus and washed out the pleural cavity. The opening having 
closed, and the physical signs indicating the reaccumulation of a considerable 
quantity of liquid, we were preparing for a second operation when the parents 
and nurse called our attention to the fact that there were occasional severe 
attacks of coughing, during which the breath presented a very decidedly 
purulent odor. Although there was no external expectoration, as the sputum 
was swallowed, thoracentesis was postponed, and the result justified the 
decision, for the patient gradually convalesced. Except under circumstances 
like the above, empyema, when clearly diagnosticated by the employment 
of the hypodermic syringe, should be promptly treated by evacuation of 
the pus. 

Instruments to be Used, and Mode of Operating. — Ingenious instruments 
for tapping the chest have been invented by Dr. Chadbourne of New York, 
Dr. A. M. Phelps of Chateaugay, Franklin co., N. Y., and others, which by 
India-rubber packing totally exclude air, while the operation is performed 
with facility and little pain. That devised by Dr. Chadbourne has a cannula 
with two arms — one for attachment by means of tubing to the exhausting 
receiver, and the other is designed to facilitate irrigation of the pleural 
cavity. 

Phelps's apparatus has a third tube, entering the bottle through the 
stopple, and a glass tube passes from the stopple to nearly the bottom of the 
bottle. With this apparatus, by reversing the movement of the syringe, the 
liquid can be withdrawn from the chest, the bottle emptied of it, the water 
used for irrigation be conveyed into the bottle, from the bottle to the chest, 
and back into the bottle, without changing the position of the bottle or 
removing the stopple. The use of the trocar and cannula instead of the 
sliding aspirator point, which plays outside the cannula, is an improvement 
in this instrument. 

The instrument to be preferred is of simpler construction. The cannula 
is about the size of the smallest needle of Dieulafoy's aspirator — the proper 
size, in my opinion, for thoracentesis for both sero-fibrinous and purulent 
exudations. I greatly prefer the use of the exhausting-bottle rather than the 
exhausting-pump without the bottle, as it is more convenient and produces 
greater suction from its greater size. The cannula is provided with an arm 
which connects it by tubing with the exhausting-bottle. Beyond this arm 
the body of the cannula, sufficiently expanded to contain India-rubber pack- 
ing, extends about one and a half inches and is provided with a stopcock. 
Through this packing the trocar is introduced, and after the puncture it is 
withdrawn to the stopcock, which is then turned to prevent the admission of 
air. Then the obturator is introduced in place of the trocar, so as to remove 
any obstruction which may enter the cannula. 

The tubing which extends from the arm of the cannula to the bottle should 
be firm, with a somewhat larger bore than that of the cannula, and its point 
of attachment to the bottle should also be provided with a stopcock. A short 
glass tube introduced into this tubing near the cannula is convenient for 
noticing the character of the fluid, which, if it be thick pus, may flow with 
difficulty and not reach the bottle. A bottle of sufficient capacity to hold 
two quarts obviously produces more suction power than one of less size, and 



PLEURISY. 903 

is therefore preferable for certain cases, and its sides should be marked to 
indicate ounces and drachms. The tube which connects the cannula with the 
bottle enters through the stopple, and proceeding from the stopple is another 
tube similar to the first, to which the syringe is attached. The syringe has 
two points for attachment to the tube and a double action in its interior, so 
that attached by one point it exhausts the air from the bottle, and attached 
by the other point it condenses air in the bottle. The stopcock between the 
cannula and the bottle should always be closed when the syringe is used, 
whether for exhaustion or condensing. It is very important that this should 
be constantly borne in mind when working the syringe, or air may be thrown 
into the pleural cavity and much harm done. 

Mode of Operating for Sero -fibrinous Exudations. — In the following 
remarks I shall state what I consider the best method for performing 
thoracentesis, having formed my opinion from the cases which I have 
witnessed and been able to follow in institutions and in family practice. 
A mode of treatment which may be safe and proper for the adult is not" 
always the best for the child, and, as there are different opinions and differ- 
ent modes of procedure, and as many who are familiar with adult cases 
recommend similar treatment for the child to that which they have employed 
with success for the older and more robust cases, I shall advise the abandon- 
ment of certain measures which are in common use and the substitution of 
others. The hypodermic syringe should be first used at the point where it 
is proposed to perform the operation, the disinfected needle being inserted 
about one inch, for I hold it unjustifiable to tap the chest without first ascer- 
taining that there are no adhesions at the site selected for puncture, and at 
the same time ascertaining the character of the liquid. Incision of the skin 
with the knife and spraying the surface with ether are not required as pre- 
liminary treatment, since the puncture is quickly and easily performed with 
a small trocar and with very little pain. The rule is established by many 
observations that the operation should be performed in or near the vertical 
line passing through the angle of the scapula and between the eighth and 
ninth ribs or one of the adjacent intercostal spaces. I have elsewhere stated 
that a point a little external to this line is preferable, as the lung is less liable 
to be injured. The instrument should obviously be inserted no farther than 
will be sufficient to reach the liquid, and, since from measurements which I 
have made the thickness of the thoracic wall in rather fleshy children is about 
half an inch, penetration to the depth of one inch will ordinarily be sufficient 
to pass the fibrinous layer. We are liable to puncture more deeply than is 
necessary without some safeguard, and incur the risk of wounding the lung. 
India-rubber tubing may cover the instrument to within one inch of the end, 
or a cord may be tied snugly around the instrument at one inch from the tip. 
The sensation communicated to the fingers will, however, be the best guide 
to the careful operator as regards the exact depth to which the instrument 
should be carried. The trocar should now be withdrawn, the obturator intro- 
duced in its place, the air exhausted from the bottle, and then the stopcock 
turned to allow the liquid to escape. 

It should flow slowly, as it probably will through so small a cannula, but 
the flow can be regulated by the stopcock. The quantity to be removed 
depends upon the age and condition of the child, the size of the cavity, and 
the quantity of the liquid, but if the patient begin to cough or feel uncom- 
fortable after the removal of one-half, or even one-third, of the liquid the 
cannula should be withdrawn. The sensation of insufficient breath is no 
longer experienced, and the remaining liquid is progressively absorbed. This 
operation is one of the easiest in surgery, while, with the precautions men- 
tioned above, no ill effect need be apprehended. One operation is, in most 



904 



LOCAL DISEASES. 



instances, all that is required, though if need be it can be repeated after some 
days, and it is very seldom that the lung does not fully expand to fill the 
chest if the operation be performed at the proper time. 

Mode of Operating for Empyema. — It will aid in understanding this part 
of our subject to remember that all pleuritic exudations contain pus-cells, and 
that the only anatomical difference between sero-fibrinous exudations and 
empyema is in the proportion of these cells. There is, therefore, a fixed 
and definite boundary-line between the two kinds of exudation. The term 
tC empyema " is, as all know, applied by common usage to the liquid when it 
contains so many leucocytes or pus-cells that a turbid appearance is imparted 
to it. Absorption is slow and difficult or impossible if the liquid contain a 
large amount of solid ingredients — to wit, fibrin and pus-cells — while liquid 
containing only a small proportion of these constituents more readily enters 
the absorbents. In other words, thin pus may be absorbed and removed from 
the system by natural methods, or by the same instrument and operation 
which we have recommended for sero-fibrinous exudations, while a thick 
liquid adherent to the pleura or sinking heavily in dependent portions of the 
cavity disappears very slowly, losing by absorption only a little of the liquor 
puris, while the bulk of it cannot be absorbed, so that the only relief is by 
evacuation through an opening. Often in practice, after the acute symptoms 
of an empyema have in a measure abated, the physical signs indicate some 
diminution of liquid in successive weeks, but further removal soon comes to 
a standstill and the resources of surgery must be tried. 

The same small trocar and cannula, or a little larger, should be used for 
tapping the chest of an empyemic child which we have recommended for 
sero-fibrinous exudation, and with the same precautions. If the liquid be thin 
and but slightly turbid, if it be but little removed from sero-fibrin in its cha- 
racter, it will flow through the cannula, even if it be necessar}^ to use the 
obturator often to remove obstructions. Having withdrawn all the liquid 
which will flow through the opening, unless severe coughing or some unpleas- 
ant symptom occur, which is an indication to discontinue the withdrawal, the 
instrument is removed and the aperture may be closed with adhesive plaster. 
In exceptional instances, if the pus be thin and the pus-cells few in propor- 
tion to the amount of serum, one aspiration may be sufficient to effect a 
cure ; but usually the cavity refills. If the pus be thick, it will almost 
inevitably refill, and it is better to make a free incision with a bistoury at 
once. If the pus be thin and the cavity after aspiration refill in a few weeks, 
free incision is preferable to a second aspiration, for as a rule the lung should 
not be compressed by pus more than four to six weeks, as by longer com- 
pression it might be seriously injured. 

Therefore, if the chest refill after one or at most two aspirations, an incision 
should be made with the knife at the same point as that selected for aspira- 
tion — that is, between the eighth and ninth ribs and in the line passing per- 
pendicularly through the lower angle of the scapula. An incision should be 
made with a sharp-pointed bistoury a little nearer the ninth than the eighth 
rib, sufficiently large to admit the blunt-pointed bistoury, and with this the 
incision should be extended to the distance of one-third to one-half inch, 
which will allow the pus to flow out freely. The opening should then be 
covered by oakum confined by long strips of adhesive plaster. Pus may or 
may not continue to flow into the oakum. If it do not, the opening will 
close, if left to itself, within two or three days. No tent or drainage-tube is 
employed, for reasons to be mentioned hereafter. The physician should 
return after twelve or twenty-four hours, not later, and should introduce 
through the opening the ordinary gum-elastic male catheter, warmed so as to 
be flexible and strongly bent at its middle. The point should be directed to 



PLEUEISY. 905 

the bottom of the cavity. Perhaps the soft-rubber catheter might be prefer- 
able, but I have never used it, being satisfied with the other. The catheter 
should be attached by tubing to the exhausting-syringe or bottle, and any 
pus in the depending portions of the cavity will be readily removed. I have 
generally at this visit removed from the bottom of the cavity two or three 
ounces, sometimes very thick, and such as would not readily flow from the 
opening. Every day or twice daily the operation should be repeated ; which 
will. I think, more effectually remove the pus than washing out the cavity, 
and the opening cannot close. This operation detains the physician only a 
few moments. The catheter should be a No. 10, and it is the best possible 
probe. By the close of the first week the opening becomes fistulous. 

After each removal of the pus long strips of adhesive plaster firmly 
applied over the ribs, from the sternal region downward and backward, 
facilitate approximation of the pleural surfaces and obliteration of the cavity. 
During convalescence the patient, if old enough, should be directed to make 
full inspirations, which serve to expand the lungs. 

That so simple and important an operation as thoracentesis should have 
been known and practised by the ancients — even, it is said, by Hippocrates — 
and have fallen into disuse till it was revived in our own times by Bowditch 
and Trousseau, seems remarkable. This was probably in part due to the bad 
instruments employed, and in part to the fact that in olden times the opera- 
tion was performed in the anterior walls of the chest, where adhesions are 
frequently present. But there are certain accidents and unfavorable results 
of the operation which may be profitably considered, since they can nearly 
always be avoided : 

1st. The Admission of Air into the Pleural Cavity. — This is unnecessary 
and can be avoided, but those who have often witnessed the operation as 
ordinarily performed have remarked the fact that the admission of more or 
less air is common. 

The entrance of a certain amount of air into a serous cavity when the 
serous membrane is in its normal state does not appear to be productive of 
harm with ordinary precautions as regards temperature, etc., as in ovariotomy, 
in which air is admitted into the largest serous cavity in the body ; and the 
moderate admission of air into the pleural cavity when the pleura is healthy 
does not, as a rule, produce any ill effect. Thus, a case is related of a man 
who suffered from heart disease, and was led to think that the pressure of a 
small amount of air internally might be substituted for external pressure, 
which always gave relief. 1 He was his own instrument-maker and operator. 
He constructed a small tube about as slender as a common pin, to which a 
bladder was attached filled with air. The point of this was thrust through 
an intercostal space till it penetrated the pleural cavity, and air was made 
to enter by compressing the bladder. Belief always followed and the 
patient's health improved. This treatment was continued two or three years. 
Dr. Lizars, who was present at the meeting of the medical society before 
which this case was related, stated that he had performed a similar operation 
on four or five patients affected with aneurysms, with some apparent benefit 
and in no case with injury. 

But the condition is very different if there be inflammatory products in 
the cavity. It is a fact known to all observers that animal liquids withdrawn 
from the circulation and escaped from the vessels through injury or disease 
remain in a closed cavity for a lengthened period without putrefactive change 
— as, for example, a clot of blood under the scalp or pericranium of a new- 
born infant — but if air be admitted it becomes offensive within a few hours. 
The admission of air into the pleural cavity which contains exuded products 
1 London Lancet, January 15, 1831. 



906 LOCAL DISEASES. 

undoubtedly promotes putrefactive changes in the latter, and the admission 
of even a small amount of air, containing, as it does, micro-organisms which 
multiply rapidly in the animal fluids, and which appear to be the active 
agents in putrefaction, suffices to convert sero-fibrin or laudable pus into an 
offensive, irritating, and poisonous liquid, which increases the constitutional 
disturbance and the gravity of the disease. 

Air in the pleural cavity, in proportion to its quantity, also tends to pre- 
vent the approximation to each other of the pleural surfaces and the oblitera- 
tion of the cavity, which is required in all empyemic cases, since this is the 
mode of cure. Obviously, the entrance of air does less harm if there be a 
fistulous opening, and pus escape as soon as it forms, than in a closed cavity, 
but it should in all instances be avoided, as never beneficial and likely to do 
harm in the manner indicated. It is never a necessary accident of thoracen- 
tesis, since it can be avoided by the use of proper instruments provided with 
India-rubber packing and stopcocks. There can be no doubt, also, that the 
point of the aspirator has often so pricked and torn the lung that air has 
entered the cavity from this organ — a result avoided by judiciously using the 
trocar and cannula. 

2d. Injury to the Lung by the Surgical Instruments Used. — The lung is 
sometimes injured by the point of the hypodermic needle employed for 
diagnosis. Cases are reported in the hospitals of New York of the break- 
ing off and loss of the needle in the lung from sudden and strong move- 
ment of this organ, as in coughing. The most severe injury is, however, 
commonly produced by the aspirator needle, and some very serious cases 
of this accident have occurred in which the needle so pierced and tore 
the lung that not only air escaped from it, but also a considerable quantity 
of blood. It is obvious that the danger of injuring the lung is greater in 
recent than in chronic cases, and greater in sero-fibrinous than in purulent 
pleuritis, for a thickened, infiltrated, and firm pleura affords protection to the 
lung. It is very difficult to avoid injuring this organ if suction be made and 
the liquid be withdrawn with the unguarded point of the aspirator needle 
projecting into the chest. The removal of the liquid necessitates the 
impinging of the lung upon the point of the instrument even if it be held 
very obliquely, and in recent cases, when there is a little thickening and 
infiltration of the pleura, the surface of this organ may be pricked or torn 
sufficiently to allow air to escape and hemorrhage occur, when the operator 
who holds the needle can scarcely believe that such an accident were possi- 
ble, so slight has been the sensation communicated to the fingers. Thus, 
thoracentesis was performed on an infant of two months which had severe 
empyema of short duration. The instrument was held by myself obliquely, 
and it entered the pleural cavity only a short distance, and yet the lung was 
injured in three places, from which it was probable, from the signs and 
symptoms, that air had escaped. The specimen showing the injury was 
exhibited to the Pathological Society in 1879. Obviously, to prevent this 
injury aspiration should be performed through the covered needle, as that of 
Phelps's or Potain's, or the trocar which I have recommended above and 
prefer. I must here repeat what has been stated above, not to plunge the 
trocar to a greater depth than is needed, which is about one inch. The end 
of the cannula may also injure the lung if it be pressed in too deeply, since it 
is necessarily rather sharp from its small size. 

3d. Washing out the Pleural Cavity. — Since the aspirator has come into 
general use it is the common practice to wash out the pleural cavity with 
carbolized water in. the treatment of empyema. The proportion of carbolic 
acid to water commonly employed is about one part to eighty, and at a tem- 
perature of 100°. From a discussion at the meeting of the New York Sur- 



PLEURISY. 907 

gical Society, Oct. 12, 1880, it appears that the use of carbolized water 
involves risk of carbolic-acid poisoning in case the liquid be only partially 
removed after it is thrown into the pleural cavity ; and the late Prof. Erskine 
Mason was in the habit of employing salicylic acid, one part to the hundred 
of water, in place of carbolic acid, since it possesses all the advantages with 
none of the possible risks of the latter. He stated that it promptly deodor- 
izes fetid pus even in the proportion of one part to two hundred. The use 
of carbolic acid would probably be entirely safe if the liquid were removed 
immediately after washing the cavity, but for some reason this is not always 
possible. In case of an infant with empyema under treatment of Drs. Lock- 
row. Billington, and myself, after removing the pus by trocar and cannula 
attached to the exhausting-bottle, and once washing out the pleural cavity, 
the liquid was thrown a second time, 3iij, into the left pleural cavity of 
an infant of five months, but not a drop of it could be removed. There 
was. however, no symptom which we could refer to the carbolic acid. In 
view of these facts and the possible danger of carbolic-acid poisoning, the 
use of salicylic acid appears to be preferable, at least for children, who are 
less able to resist the action of poisonous agents than adults. 

Iu this connection I must state my conviction that washing out the 
pleural cavity is unnecessary if empyema be treated as recommended above, 
and it may be injurious. But it is proper treatment when the pus has 
undergone decomposition, is offensive to the smell, and therefore poisonous. 
If it be putrid, its immediate disinfection as well as removal from the pleural 
cavity appears to be clearly indicated, but in the common form of empyema, 
as the pus escapes through the opening which has been made and the suppu- 
rative cavity becomes smaller, adhesions of the pulmonary and costal surfaces 
occur, which the injection of water may tear up and destroy, and thus the 
obliteration of the cavity is retarded. Letting out the pus and approxima- 
tion of the pleural surfaces to each other are the indications as regards surgical 
measures. Besides, washing out the pleural cavity is not devoid of danger. 
Alarming symptoms may be developed unexpectedly and rapidly, even when 
the operation is slowly and cautiously performed. The infant of five months 
with empyema whose case I have alluded to furnished a striking example 
of this. Four ounces of pus had been removed through a small cannula 
from the left pleural cavity, and without removing the cannula the cavity 
had been once washed out. It was proposed to repeat the washing, as the 
infant had thus far tolerated the operation and was in an unusually favorable 
state for a case of empyema. The patient was in a semi-erect position, and 
three ounces of water at a temperature of 100° had entered the cavity from 
the inverted bottle, when he began to cough, fretted, and became very rest- 
less. Immediately Dr. Lockrow applied the suction-point of the syringe to 
the tubing, and attempted to withdraw the liquid, but with no result. The 
patient's face assumed a deadly pallor ; he frothed at the mouth, his lips were 
compressed, and breathing ceased. He was to all appearances dead. He was 
immediately placed upon the back by Dr. Billington, and by prompt resort 
to artificial respiration the terrible suspense was soon ended by the gasps 
of the child and the return in a few moments of consciousness and normal 
respiration. It seemed to me that this untoward accident was due to the 
flow of water against the heart, so that it prevented full dilatation of its 
cavities, and consequently diminished the flow of blood into the aorta and 
produced anaemia of the brain. Lichtenstern says : " Various causes which 
sometimes quite interrupt or impede the flow of blood to the left heart, such 
as severe paroxysms of coughing, vomiting, lifting heavy burdens, may give 
rise to a suddenly fatal anaemia of the left heart, and secondarily of the brain. 
The anaemia of the lungs or brain found in many cases is only of secondary 



908 LOCAL DISEASES. 

importance. It frequently happens, after thoracentesis with aspiration that 
an anaemia is produced in the partially-distended lung, and this may lead to 
death by asphyxia. In sudden death during, immediately, or a short time 
after thoracentesis by aspiration the cause is anaemia, either of the heart or 
brain. In cases in which severe syncope and sudden death are observed 
during the irrigation of the pleural cavity the cause is either direct mechani- 
cal concussion of the easily-exhausted heart by the stream of water thrown 
in, or shock. 1 ' x 

4th. The Use of Tent and Drainage-tube in Empyema. — With due regard 
for the opinions of the experienced surgeons who employ and recommend the 
tent and drainage-tube, but whose observations have been largely upon adult 
cases of empyema, I cannot recommend their employment for children, unless 
perhaps the tent for a day or two after the incision ; but the tent is not 
necessary if the catheter be daily introduced in the manner which I have 
advised. The drainage-tube almost necessarily admits air during inspiration, 
but this is not the most serious objection to it. Cachectic children with 
poorly-nourished tissues badly tolerate pressure upon an open wound by a 
hard substance. It is liable to cause ulceration and enlarge the opening, 
and continued pressure of the tube may cause periostitis upon the edge of 
the rib and necrosis. Scrofulous and feeble children are very prone to both 
caries and necrosis from even slight pressure or bruises upon the surface 
of the bone — a result to which adults are much less liable. In a paper pub- 
lished by Mr. W. Thomas 2 on the treatment of empyema by resection of one 
or more ribs, 9 cases are detailed, in 3 of which necrosis had occurred from 
pressure, it is stated, of drainage-tubes, thus necessitating the removal of the 
diseased portion. During the year 1881 a wasted empyemic infant was 
brought to one of the institutions of this city for treatment. After letting 
out the pus a drainage-tube was introduced and secured. At the next visit 
ulceration had so enlarged the opening that a large amount of air entered 
the chest, with a whistling noise at each inspiration, and was expelled during 
expiration, and necrosis of the portion of the rib against which the tube 
pressed had also occurred. Air was finally excluded by covering the opening 
with a cloth smeared on each side with a concentrated solution of gutta- 
percha in chloroform, but the case after some days ended fatally. The 
escape of the drainage-tube into the pleural cavity, which has occurred by 
breaking of the threads which secured it, is so rare an accident that it does 
not constitute an objection to the introduction of the tube ; but aspiration 
daily or twice daily through the catheter so completely removes the pus that 
drainage is not required, and the risk of injury by the pressure of the tube 
is therefore avoided. 

5th. I have witnessed in a few instances the burrowing of pus under the 
skin at the point where an incision had been made to let out the pus. This 
complication may lead to more or less ulceration or sloughing, and it greatly 
increases the danger of poisoning. But infiltration of pus will almost never 
occur if the incision be direct through the tissues, and not with the skin 
pushed to one side, so that it forms a covering or valve when it returns, as 
was once recommended in the books as a means of excluding air. But air 
does not enter the cavity through a direct opening if it be properly covered 
after the pus has escaped. Burrowing of pus and pyaemic poisoning there- 
from cannot, then, be regarded as an accident of the mode of operation which 
I have recommended. 

Paracentesis thoracis, tapping the pleural cavity to withdraw fluid accu- 
mulated in it, is required — (1) where fluid is so copious as to fill one pleura ; 

1 Leutsches Archiv fur klin. Med. , Band iv. 4 Heft ; London Med. Record, Dec. 15, 
1880. 2 Birmingham Med. Bee., 1880, N. S., vol. iii. 



PLEURISY. 



909 



(2) when, the effusion being large, there has been one or more fits of ortho- 
pnea : (J3) when the contained fluid is purulent ; (4) where a pleuritic effu- 
sion occupies as much as half of one pleural cavity ; and (5) when it shows 
no signs of progressive absorption. The operation should be preceded by an 
exploratory tapping with a hypodermic syringe to determine the kind of 
fluid. 

Fig. 244. 




Trocar and canunla. 



The instrument consists of a trocar and cannula (Fig. 244), the latter being 
fitted to screw upon a flexible suction-tube of the syringe ; the cannula should be 
provided with a stopcock ; the trocar and cannula being introduced within the 
chest, the trocar is withdrawn and the cannula attached to the syringe ; the liquid 
is then removed by means of the expansion of the India-rubber suction bag after its 
compression with the hand. Any form of aspirator may be used, or the common 
trocar and cannula, but in the latter case air must not be allowed to enter unless 
antiseptic spray is used. 

The place of operation will vary, within given limits, according to the 
amount of fluid collected. The indications are, to secure a sufficiently de- 
pendent position and to avoid wounding the arteries and the diaphragm. In 
general, the lower portion of the intercostal space must be selected, as the 
intercostal arteries approach the centres of the spaces posterior to the angles 
and anterior to the anterior third of the spaces ; 

the upper limit should be the sixth rib, and Fig. 245. 

the lower the eighth rib on the right and the 
ninth rib on the left (Fig. 245). The point 
to be selected when there are no special indi- 
cations is the sixth intercostal space on the 
right, owing to the liver, and the seventh on 
the left and midway between the spine and 
the sternum. Some tap, by preference, below 
the angle of the scapula and between the sev- 
enth and eighth ribs, or the eighth and ninth 
ribs, at a point distant from two to three inches 
from the angles. 

Operate as follows : Let the patient sit across 
the bed so as to admit of the body being readily 
lowered and supported over the edge ; carbolize all 
of the instruments ; make a small puncture in the 
skin, just at the upper edge of the rib, with a nar- 
row-bladed lancet or knife ; puncture the cavity 
through this incision, steadying the trocar with Points for tapping, 

the fore finger of the right hand pressed upon the 

chest, giving the instrument a slight obliquity upward, which will enable it to clear 
the edge of the rib, and a rotary motion ; the depth to which the trocar or needle 
penetrates must depend on the thickness of the parietes, the presence of fat, muscle, 
or oedema, for which due allowance must be made. 

Or, find the inferior limit of the sound lung behind, and tap two inches higher 




910 



LOCAL DISEASES. 



than this on the pleuritic side, at a point in a line let fall perpendicularly from the 
angle of the scapula ; push in the intercostal space here with the point of the finger 
and plunge the trocar quickly in at the depressed part ; be sure to puncture rapidly 
and to a sufficient depth, to prevent the occlusion of the cannula by the false mem- 
brane. The amount of fluid withdrawn in any case must depend upon the condi- 
tion of the patient and the lungs, care always being taken to avoid faintness. When 
the flow ceases, instantly withdraw the cannula, and place the point of the finger on 
the puncture until adhesive plaster is applied. If the common trocar and cannula 
are used, the outward flow of fluid must not be allowed to intermit, lest air enter 
the cavity. 

If the cavity is filled with pus, drainage-tubes must be employed. Select 
a trocar and cannula of the size of a No. 12 catheter, and rubber tubing No. 
10 catheter, having several fenestrse cut in the sides, and four inches in 
length. 

Cleanse the region of the wound with soap and water and bichloride solution ; 
make an incision through the skin at the point of puncture with the scalpel, and 
thrust the trocar into the cavity firmly, giving a slight rotary motion to the point ; 
withdraw the trocar, and as the pus flows introduce the carbolized tube through the 
cannula into the chest-cavity. To prevent its escape the tube must be transfixed 
with a safety pin. Or, incision may be made directly into the pleural cavity, select- 
ing the upper margin of the rib, and when pus begins to flow the tube may be intro- 
duced with slender forceps. 

There have been many instances of the escape of the tube into the cavity due to 
defective fastening, as by safety-pins. The following method has been proposed : 
Cut a round hole in a piece of red India-rubber sheeting one-twelfth of an inch 
thick and about one and a half to two inches square ; split a tube of the size re- 
quired, and without holes, at one end into four pieces, and draw it through the hole 

in the flat piece of rubber, turned 
down and fixed in position by 
stitches of fine silver wire. The 
tube should be just long enough 
to project into the chest-cavity — 
one and a half to two inches — 
according to the thickness of the 
chest-wall. Nothing is gained by 
curling up an enormous length of 
tubing in the chest. Such a tube 
adapts itself to a sinus leading in 
any direction, and requires no 
special manoeuvre to prevent it 
entering the chest. These tubes 
can be made in a few minutes, of 
any size required, by the physi- 
cian himself. 

If a tube escape into the cav- 
ity, proceed as follows : If the case 
is seen within a short time of the 
accident, before the position of 
the tube has been changed by cough or other movement, we may seize the tube with 
forceps introduced into the wound ; if the orifice be too small to admit the forceps, 
use a sponge-tent or dilator. In using the tent we must bear in mind the possible 
existence of a bony ridge of union between the ribs in chronic cases, the tract 
passing through an osseous ring. The attempt to enlarge such a sinus by means of 
a sea-tangle tent has necessitated the removal of a portion of two ribs. In order to 
gain the required sense of touch it is advisable to pinch an India-rubber tube with 
forceps before blindly searching the cavity. A wire curved properly, with a hook 
at the end, has enabled the operator to fish up the tube. 

If we fail after passing forceps of various kinds into the thoracic cavity in dif- 
ferent directions, place the patient in the horizontal position, the fistulous opening 
being most dependent, and then search again with forceps, bent probe, etc. ; not 
succeeding, inject the cavity with water, in the hope that the return stream will 




Drainage-tube for pleural cavity. 



PLEUBISY. 911 

carry the tube into the vicinity of the opening. These means proving unsuccessful, 
enlarge the orifice with a knife, so that the finger can be introduced. If the space 
be still too small, a portion of a rib must be removed in order to accomplish our 
object. Bear in mind that the adhesions which have occurred between the pul- 
monary and costal pleura in some cases will probably retain the foreign body in the 
neighborhood of the fistula, rendering the removal a simple and easy process. The 
case is apt to be more serious if the affection be recent : adhesions not having had 
time to form, the tube has probably gained the most dependent portion of the cavity, 
and will in all probability be found in the costo-diaphragmatic sinus. The compli- 
cation is greater if the original incision have been made high up. A second open- 
ing in one of the lower intercostal spaces may be required before we can reach the 
tube in the chest. 

Excision of the rib must be practised in more severe cases of empyema. 
The ninth rib is selected by G-odlee, because it is just above the point where 
the diaphragm is united to the ribs when it has been drawn up as much as 
possible, and is also the most dependent part when the patient is in a recum- 
bent position. It is, therefore, the most suitable place for drainage of the 
entire cavity, both anteriorly and posteriorly. 

Make an incision over the rib, two or two and a half inches in length, down 
to the bone ; the periosteum is then raised from the bone the length of the 
wound, in front and behind ; bone-forceps are now applied and about an inch 
of the rib is removed, the anterior cut being made first. The ends of the 
bones must be rounded off with a raspatory. The pleura must now be cau- 
tiously opened. It may be punctured with a director and the opening en- 
larged with forceps, or it may be incised if it is very dense. When opened 
sufficiently the patient must be turned upon his back and the pus allowed to 
flow out freely. The cavity should not be irrigated unless the pus is offen- 
sive, when hot boric-acid solution may be injected. A drainage-tube (Fig. 
246) must be fixed in the wound and antiseptic dressings applied. The tube 
is retained, smaller tubes being used as the discharge declines, until the flow 
ceases. In some cases the eighth rib may also require exsection. The 
recovery of the patient is usually rapid and the repair complete, for new 
bone will form and replace the lost. 



SECTION V. 

DISEASES OF THE CIRCULATORY SYSTEM. 



CHAPTER I. 

DISEASES OF THE HEART. 

The heart is liable to many forms of malformation, but those defects 
which give rise to cyanosis are of the greatest practical importance. This 
subject has already been considered at length. 

The position of the heart in childhood has not hitherto been sufficiently 
understood. Recently more accurate studies of frozen sections have deter- 
mined some facts of interest. Symington 1 concludes that the cardiac im- 
pulse in infants and children usually takes a more external position than in 
adults, for while in the latter the impulse is usually about an inch internal 
to the nipple line, in children it is usually either in the nipple line or it may 
be 11 inches external to that line. This he attributes to the greater relative 
narrowness of the infant's chest in the transverse diameter, while, at birth 
at least, the heart is relatively larger than in the adult. Some are of the 
opinion that when the impulse is raised, it is visible in the fourth instead of 
in the fifth intercostal space. Rotch alludes to the fact that, owing to the 
small size of the child's thorax, the heart and pericardium are much nearer 
the anterior surface of the thoracic cavity than is the case with these organs 
in the adult. This occurs both normally and in diseased conditions, especially 
where there is flattening, and thus levelling, of the chest. Under these con- 
ditions the heart and pericardium are brought in such close contact with the 
examiner's ear that on palpation he will feel the heart's impulse, and on aus- 
cultation will hear the heart-sounds in a more advanced stage of the effusion 
than would be possible in the adult with a proportionately large increase of 
the fluid. Ashby says it is due to the frequency with which the stomach 
and bowels are distended with gas during childhood, pushing up the diaphragm 
and heart. Symington found that the position of the heart and great vessels 
is, normally, practically the same as in the adult. 

Functional Disorders. 

DaCosta, 2 who has written ably on this subject, calls attention to the fact 
that up to about the seventh year the heart's action is often of unequal 
strength and rhythm, and prone to be irregular in the healthiest children 
during sleep, and greatly influenced by the act of breathing. When the 
irregularity persists during waking hours and quiet breathing, it indicates 
cardiac disorder unless there are evidences of meningeal disease. A form 
of irregular action is mentioned that is regarded as idiopathic, in which ir- 
regular rhythm constitutes the entire malady. The heart's action is at times 

1 Ashby and Wright, Dk Chil. 

2 Cyclopaedia Dis. of Children (Keating). 
912 



PEBICABDITIS. 913 

verv slow, having sixty or even fifty beats ; intermissions are common, or 
there is a series of small beats followed by fuller strokes ; the first sound may 
be defective : the organ is impressionable, and exhibits in a marked manner 
the influence of the respiratory act, becoming irregular if the breath is held. 
This changed rhythm appears at from three to six years ; rarely in infants. 
On the occurrence of a fever the irregularity disappears. It sometimes 
appears to be hereditary. 

The diagnosis is not difficult. There is. as in the adult, increased im- 
pulse, normal percussion dulness, distinct second sound, and first sound either 
weak and short or sharp and valvular. 

The prognosis is favorable in those cases in which a removable cause is 
discovered. The least promising cases are those of the idiopathic variety, 
where the heart is impressionable. No permanent injury to the heart, as 
dilatation, has been detected. 

The treatment consists in the removal of every condition which seems 
to cause or aggravate the trouble. Careful regulation of the diet and of the 
digestive organs is important. If there is anaemia, iron, arsenic, liberal diet, 
out-door exercise, and sea-bathing are the remedies. Light gymnastics, prop- 
erly guarded, are useful. The most serviceable heart-tonic is tr. digitalis, 3 to 
5 drops to a child of six years of age, soon after meals. It must be continued 
several months, with intervals of ten days every month. Belladonna is some- 
times useful in connection with digitalis or as a substitute for it. 



CHAPTER II. 
PEBICABDITIS. 

This disease is most frequent in the later years of childhood, but it may 
occur in infancy, and even in the foetus (Billard, Bednar). As in the adult, 
rheumatism is the more frequent cause of pericarditis in children. Though 
there may be no outward manifestations of rheumatism, as swelling of the 
joints, still there can be little doubt that after the age of five the conditions 
which cause rheumatism in the adult are often present. Pericarditis may 
complicate pleuritis, especially in infants, or be caused by septicaemia, peri- 
ostitis, and osteitis, or follow scarlet fever and other eruptive diseases. It is 
always important to examine the heart when a child is passing through any 
severe disease, as the exanthemata, pleurisy, pneumonia, for frequently peri- 
carditis is masked by other symptoms or conditions. Its existence is often 
suddenly made apparent by severe symptoms, as dyspnoea, when it may have 
been in progress several days. 

The pathology of pericarditis in children differs in some respects from 
that of the same disease in adults. In the former there is a greater tendency 
to effusion, and it occurs earlier and more rapidly. Hence dry pericarditis 
(sicca) is rarely met with in children. The effused fluid is also more likely 
to be tinged with blood, owing to the rupture of minute capillary vessels, 
but this symptom has no special significance, as in the adult. It is notice- 
able also that the effusion is more liable to become fibrinous, and even puru- 
lent, in children, especially when suffering from some other affection. This 
latter condition is due to the susceptibility of the child to the lodgement of 
the pus-microbe, derived from some suppurating surface in the system, on the 
walls of the vessels of the pericardium damaged by inflammation. The child 

58 



914 LOCAL DISEASES. 

rarely suffers from tuberculosis of the pericardium, compared with the adult, 
as it is not so liable to the formation of tubercle in the bronchial glands. 

The symptoms of pericarditis in the child are liable to be very obscure 
at first. Pain is unreliable, fever may be slight, and dyspnoea absent. It is 
only by physical examination that its presence is detected. A friction-sound 
is early heard ; then there is an increased area of dulness on percussion ; the 
apex-beat is obscure and is felt more widely, sometimes in the fourth and fifth 
spaces, and dyspnoea may become marked, with a tendency to orthopncea. In 
an ordinarily well-marked case the reliable symptoms are — 1. a friction-sound 
of the pericardium ; 2, diminution or disappearance of the apex-beat ; and 3, 
an increase of the area of percussion dulness. 

Diagnosis. — If the practitioner is intelligently watchful of his patient. 
he will detect the friction-sound before the disease is indicated by any other 
symptom, and even before it may have been suspected from any apparent 
condition existing. The effusion at this moment has not taken place, or is of 
small amount. This friction-sound varies much in its intensity, depending 
upon the condition of the surfaces which rub together. Thus, if the surfaces 
are very dry, as is the case before plastic material is thrown out, the sound 
will be very harsh, and may even be grating in its intensity. This sound 
marks an early, probably the earliest, recognizable stage of the disease. As 
the surfaces become lubricated by the effusion the friction-sounds change, 
becoming less harsh, until they finally disappear as the surfaces become com- 
pletely separated by the increasing accumulation of fluid. 

The diminished heart-beat follows upon the loss of the friction-sound, and 
is due to the same cause — viz. effusion into the pericardium. Its complete 
absence marks the distention of the cavity to such an extent that the apex 
no longer impinges upon the pericardial wall. 

If the friction-sound has escaped detection. Rotch regards percussion as 
the most important method of determining whether pericarditis is present, 
and as the best guide to prognosis and treatment. 

He states that in effusions of exactly the same amount the area of dulness may 
differ, owing to the difference in the elasticity of the lungs and the presence or ab- 
sence of adhesions. The greater the elasticity of the lungs and the fewer the adhe- 
sions, the more regular will be the outline of absolute dulness and the greater its 
significance as compared with that of the relative dulness, while the reverse of this 
is true of the relative dulness. Thus, the absolute dulness is determined by the 
retraction of the borders of the lungs, which withdraw from the chest-walls as the 
effusion gradually distends the pericardium. The enlargement of the area of rela- 
tive dulness is due to the distended pericardium compressing the lungs, which may 
be held more or less in position by adhesions. Again, the greater the elasticity and 
the freer the displacement the greater will be the compression. 

If the effusion is slight, the area of dulness is limited to an extension in 
the fifth intercostal space and below the nipple. At this time it may be dif- 
ficult to define the boundary of the effusion, or even to determine satisfac- 
torily its existence. But when the pericardium is filled, its capacity at the 
age of eight being about six ounces, the area of dulness is increased laterally 
and the left lung is displaced outward and upward. When the effusion is 
very great, the dulness extends not only laterally on the left side, but also 
on the right side of the sternal border, and upward to the second intercostal 
space. 

Rotch states that, owing to the. flexible thorax of the child, there is a 
greater opportunity for the neighboring parts to yield before the pressure of 
an effusion, and we are thus more likely to have bulging of the intercostal 
spaces, and on inspection a visible alteration of the cardiac area, than in 
adults. 






PERICARDITIS. 915 

Prognosis. — Pericarditis when diffuse is always a grave disease in chil- 
dren, and is generally fatal in infants. If there has been pre-existing disease 
of the heart which has caused hypertrophy, the effusion of pericarditis may 
embarrass its action, so as to cause rapidly fatal results. If there is valvular 
disease, as mitral regurgitation with dilatation of the left ventricle, the peri- 
cardial inflammation will almost inevitably lead to acute dilatation and speedy 
death. Organized adhesions are the more remote results of pericarditis, 
which, if extensive, permanently interferes with the action of the heart. 

Treatment. — The treatment of pericarditis in the child does not differ 
in kind from the same disease in all its forms in the adult. Of the first im- 
portance is absolute rest in bed in order to secure a quiet circulation. The 
food should be nutritious, but unstimulating, as milk. If the disease com- 
plicates rheumatism or depends upon a rheumatic condition, salicylate of soda 
and liq. ammo. acet. are most useful. If there is any evidence of cardiac 
weakness, as dyspnoea, tr. digitalis in 2- to 6-minim doses every three or four 
hours should take the place of the latter remedy. Opium always has a place 
in the treatment of pericarditis. It should be given to relieve pain and rest- 
lessness, and thus quiet the action of the heart, and at the same time promote 
the action of the skin. Dover's powder at night, in 1- or 2-grain doses, re- 
peated once or twice during the day if necessary, is very useful. 

Of local applications in the early stage, a hot flaxseed poultice, with one- 
sixth or eighth part of mustard, will prove beneficial. Other measures are 
spongio-piline wrung out of hot water and wet with laudanum ; ext. of 
belladonna, with a small amount of glycerin, spread on flannel, may be 
applied over the heart. 

When effusion has become a feature in the progress of the case, repeated 
small blisters made with blistering liquid often relieve pain and promote ab- 
sorption. If care is taken to rupture, and not remove, the vesicle in evacuat- 
ing its contents, and then applying soft dressings, as sterilized cotton, the 
blisters will create no inconvenience. 

If the case progress to the accumulation of fluid, so that the action of 
the heart is seriously embarrassed, the question of its removal by operation 
will arise. Before proceeding to operate it should be determined, as accu- 
rately as possible, to what extent the percussion dulness is due to effusion 
alone, and whether it may not be due in part or whole to dilatation or hyper- 
trophy of the heart. This question can be answered correctly only by a 
careful inquiry as to the previous history of the patient and study of the 
progress of the case. 

Rotch states that a girl aged five years entered the service of Dr. Henri Roger 
of the HSpital des Enfants Malades with all the signs of an abundant pericardial 
effusion. The case was under observation several weeks, and Dr. Roger repeatedly 
marked out the area of dulness in his usual minutely careful way, and designated 
the precise spot where he intended to insert the trocar. His colleague opposed the 
operation on general principles, and, the child dying, an autopsy disclosed no 
effusion, but an enormously dilated heart. 

If it is decided that there is little or no hypertrophy, and that the symp- 
toms are due to the effusion, aspiration of the fluid should be performed. 
The smaller needle should be selected. The point of operation is in the 
fourth or fifth intercostal space, according to the location of the apex-beat 
and the indications of distention of the pericardium, and midway between the 
nipple and the margin of the sternum. It is well to make a slight incision 
of the skin to aid the penetration of the needle. The needle should point 
upward and backward, and should be introduced with a rotary movement, 
care being taken not to penetrate too deeply, lest the heart be wounded. 



916 LOCAL DISEASES. 

Roberts prefers the space between the ensiform appendix and the seventh left 
cartilage as the safest point for tapping (Rotch). 

If the effusion is purulent and the fluid rapidly accumulates, it will be 
necessary to open the pericardium by incision and disinfect the cavity. Boric 
acid is most useful. It will be advisable to introduce a drainage-tube, as in 
a common abscess. 

There is often a strong tendency to heart failure in these more serious 
cases, which must be guarded against by the judicious use of heart stimu- 
lants and tonics, as tr. digitalis, strychnia, ammonia, and quinine. 



CHAPTEE III. 

MYOCARDITIS. 

Inflammation of the walls of the heart is a very rare affection in chil- 
dren, and may be acute or chronic. It especially affects the intermuscular 
connective tissue. It may be diffused or circumscribed. Bruce, whose arti- 
cle on myocarditis l should be consulted, states that, " microscopically, acute 
myocarditis is characterized by infiltration of the intermuscular spaces, with 
an exudation of leucocytes, sero-fibrinous material, and extravasated blood, 
and by compression and albuminous and fatty degeneration of the muscular 
fibres," 

The acute diffused form differs from the circumscribed form only in the 
area of the inflammation : in the former a large extent of the wall is infil- 
trated, while in the latter the inflammation has a limited area, more often in 
the left ventricle and septum. The appearance of the tissues is either dark 
red, injected, and frequently ecchymosed, or of a peculiar mottled yellowish 
hue ; when localized the part becomes swollen and softened, and finally of a 
grayish-red color, which precedes the formation of an abscess. The abscess 
of the wall may open into the pericardium and set up a pericarditis, or into 
a cavity of the heart, causing a cardiac aneurysm. 

Chronic myocarditis tends to a growth of the intermuscular connective 
tissue and degeneration and disappearance of the muscular fibres, more or 
less completely. 

The cause of acute myocarditis, except when it results from an injury, 
is some pre-existing disease, as endocarditis. It may also complicate acute 
articular rheumatism and infective diseases, and it may result from embolism 
when destructive diseases of the lungs or other organs are in progress. In 
general, the diffuse or parenchymatous form of inflammation occurs during 
an attack of endocarditis, rheumatism, or the exanthemata, while abscess 
results from embolism. But the progress of the two forms does not mate- 
rially differ. 

The symptoms are those dependent upon a diminution of the functional 
capacity of the heart, and a consequent weakening of the blood-pressure in 
the aortic system, over-distention of the pulmonary circulation and of the 
veins of that system (Schroetter). The pulse is frequent, weak, and often 
irregular ; the skin pale or cyanotic ; the fever usually moderate in degree. 
Auscultation reveals a feeble heart-impulse, the sounds are indistinct, and the 
area of dulness may increase laterally. 

1 Keating' s Cyclopcedia of Bis. of Children. 



EXDOCARDITIS. 917 

The diagnosis of myocarditis following diseases of the heart must be 
made in connection with existing diseases and a careful study of the phe- 
nomena as they appear connected with the heart. In idiopathic myocarditis 
the diagnosis will be based principally upon pain in the region of the heart 
and sense of constriction of the chest; anxiety, slight fever, dyspnoea, rapid, 
irregular, and feeble pulse, increasing weakness, with the gradual develop- 
ment of bronchial catarrh and the symptoms of Bright's disease. 

The treatment niust be adapted to the particular features of each case. 
Rest must be maintained, and relief from pain secured by opium or other 
narcotics. If articular rheumatism has preceded the attack, salicylate of 
sodium must be given. Proper feeding is most important, and predigested 
milk and beef are always indicated. Cardiac stimulants must be reserved 
for symptoms of heart failure, and then be administered with great care. 
Caffeine, digitalis, quinine, ammonia, and strychnine are valuable at the 
proper time. 

Chronic myocarditis and cardiac aneurysm are to be treated on the 
same principles as govern the treatment of chronic valvular disease. 



CHAPTER IV. 

ENDOCARDITIS. 

Endocarditis may be acute or chronic. In its acute form it takes its 
rise in a proliferation of the fibrous connective tissue underlying the endo- 
thelial cells of the endocardium. The most important feature of the disease 
is the cell-proliferation of the fibro-connective tissue of the valves, which 
forms nodules — the well-known vegetations. They appear at first as a series 
of gelatinous-looking, translucent beads on the margins of the valves. They 
may be absorbed or they may gradually enlarge and become opaque. As the 
disease progresses similar nodules may form on the tendinous cords and 
undergo similar transformations. 

The left side of the heart is far more often affected. The valves of the 
pulmonary artery are very rarely the seat of inflammatory changes. The 
tricuspid valve may be affected, but it more often escapes. The disease is 
usually confined to the left side, and the mitral valves are in general chiefly 
implicated. 

Sibson attributes the susceptibility of the mitral valves to the fact that the flaps 
of the mitral valves press against each other when the valve is shut with much 
greater force. 

The future disastrous consequences of endocarditis in children depend 
upon the organization of these nodular masses. Cheadle l thus graphically 
sums up the effects of endocarditis : " The changes which follow acute or 
subacute endocarditis are both grave and numerous. Fibrous contraction 
and thickening and puckering or ulceration or perforation of the valves and 
tendinous cord, leading to narrowing of the valvular openings or causing 
imperfect closure and regurgitation ; consequent changes in the cardiac 
chambers, such as dilatation and hypertrophy ; simple dilatation, partial or 
general, from injury to the muscular tissues of the walls by accompanying 

1 Keating' s Cyclopcedia of Diseases of Children. 



918 LOCAL DISEASES. 

myocarditis ; sometimes embolisms from the detachment of fibrinous concre- 
tions on the valves or from thrombi in the cavities, — all these occur in the 
case of children." 

The evidences of the existence of acute endocarditis are not always prom- 
inent in children. It often happens that these patients pass through an attack 
of rheumatic fever without a suspicion of heart complication. It is not 
uncommon to discover valvular disease in children that, on inquiry, evi- 
dently had its origin in a mild attack of rheumatism which attracted so little 
attention that medical advice was not sought. Again, we often see children 
in the first stages of a rheumatic fever who have well-marked valvular lesions. 
These cases are readily accounted for, if the previous history is carefully 
studied, as relapses of previous rheumatic seizures, during which the val- 
vular complications occurred. These facts suggest the importance of con- 
stant watchfulness of the heart in all acute diseases of children, especially 
where there is a rheumatic element in the case, although it may not be at all 
pronounced. It is also true that endocarditis often complicates chorea, ton- 
sillitis, diphtheria, and septicaemia. 

The prudent physician will not fail to examine the heart of a child even 
when the disease seems to be only a transient fever which occurs without 
apparent cause. These attacks sometimes prove to be endocarditis, probably 
from a latent rheumatic condition. 

The symptoms of endocarditis in children should therefore be carefully 
studied, in order that an early diagnosis may be made and prompt treatment 
secured. The first symptoms which indicate endocarditis are discovered by 
auscultation. This must be patiently and perseveringly practised at every 
visit, to fully appreciate the changes which are in progaess. The first dis- 
coverable symptom in an obscure case is a systolic murmur traceable to 
the mitral valves and indicating a regurgitation. It will also be noticed that 
this murmur is preceded by a dull, rumbling sound, which is due to mitral 
stenosis. Cheadle found in nearly one-fourth of his cases the systolic mitral 
and the presystolic exist together. He states that in a very small proportion 
of cases the murmur is basic and systolic, signifying aortic obstruction ; it is 
rarely diastolic, indicating aortic regurgitation ; the mitral systolic murmur 
is usually, the presystolic mitral invariably, organic and a sign of endocarditis ; 
the aortic systolic murmur is rarely hasmic or functional ; the diastolic aortic 
is invariably organic and a certain evidence of endocarditis. There is also 
often noticeable reduplication of the second sound, which is heard at the 
apex and not at the base of the heart. 

The action of the heart is variable, but usually it is increased, and may 
give a pulse of 140 to 150. There is also an increased area of dulness very 
early noticed, which at first is sometimes due rather to the increased impulse 
of the heart than to true enlargement, though the latter condition soon 
supervenes. 

In the progress of the case anaemia supervenes, and this becomes more 
marked when relapses occur in the rheumatic form of endocarditis. Hyper- 
trophy of the heart often proceeds rapidly, with its usual effects upon the 
circulation. 

The diagnosis of endocarditis depends much upon the care with which 
the early symptoms are sought for and analyzed. The first question to 
determine is as to the existence of an abnormal heart-sound. If present, 
what are its peculiarities ? If there is a murmur, consider where it is most 
distinct. If it is most intense at the apex and occurs with the systole, and 
if it is recent or commenced with rheumatism, scarlet fever, or chorea, endo- 
carditis is undoubtedly present, and has already crippled the valves. The 
subsequent development of symptoms is in the direction of the progressive 



ULCERATIVE ENDOCARDITIS. 919 

changes which the inflammation of the endocardium causes, especially in the 
integrity of the valves. 

Cheadle states that a presystolic murmur is always organic, and therefore 
its fresh appearance would be conclusive of the presence of endocarditis, past 
or present ; a systolic aortic murmur is almost invariably organic, except in 
cases of extreme anaemia ; a diastolic aortic murmur is invariably organic, 
and sometimes occurs as the earlier sign of endocarditis. 

The prognosis in a first attack of endocarditis, uncomplicated by severe 
rheumatism or other disease, is favorable. In many cases the cardiac symp- 
toms abate, and may disappear ; in others, although the valvular defects per- 
sist, the development of the heart may in a great measure compensate for 
the deficiency. In cases of recurrent endocarditis the prognosis is more 
unfavorable. Every attack aggravates more and more existing lesions ; 
anaemia, with wasting of tissues, becomes a marked feature ; rapid action of 
the heart with dyspnoea supervenes, and the case assumes a most unfavorable 
condition. 

The treatment of endocarditis in children should aim to restrain the 
action of the heart and to support the strength of the patient. Rest in bed 
is of the first importance, and everything that tends to excite physical or 
mental disturbance should be avoided. The diet should be easily digested 
and taken in small quantities, frequently, to prevent distention of the stom- 
ach. Peptonized milk, beef-tea, or sarco-peptones and parapetone, and fari- 
naceous articles, must be judiciously given. Stimulants should be employed 
only in case of threatened failure of the heart, unless septicaemia complicates 
the case, when alcohol becomes useful. 

The use of medicinal remedies must be directed according to the special 
features of each case. For high temperature, or septicaemia, quinine should 
be given freely from the first. Two to three grains every four hours may 
be given to a child of five years of age. In rheumatic cases salicin, in doses 
of five to seven grains, in sweetened water, every four hours for a child five 
years old, is preferable to salicylate of sodium, as it is not a depressant. 
To this remedy may be added alkalies, as the carbonate or citrate of sodium, 
in doses of ten grains every four hours until the urine becomes alkaline. In 
cases exhibiting a feeble pulse, but a rapid action of the heart, digitalis will 
be required in doses of three to five drops of the tincture every four hours. 
Opium, in some of its forms and in small doses, may be found useful where 
there are pericardial adhesions or hypertrophy and there is distress due to 
the violent action of the heart. 



CHAPTER Y. 

ULCERATIVE ENDOCARDITIS. 

Ulcerative endocarditis rarely occurs in children. Prof. Osier, who 
has treated the subject exhaustively in his lectures at the Royal College of 
Physicians, in his researches found records of upward of 200 cases, but few 
instances among children. It has rarely been seen in the institutions of New 
York. Kirkes, who reported the first case, discovered the disease in a boy 
fourteen years old. Cheadle states that only a single case appears in the 
records of the Hospital for Sick Children, London, where patients are ad- 



920 



LOCAL DISEASES. 



mitted under the age of twelve, during the last twenty years. He gives the 
following history : 

Case. — Child aged eight years ; had suffered from acute articular rheumatism 
three years before, and two years later was in hospital for chorea ; she soon recov- 
ered, and remained well until five weeks before admission ; was seized with inces- 
sant vomiting and headache, followed by general convulsions, twitchings, and un- 
consciousness lasted twelve hours, but no paralysis remained ; three days after had 
another attack of convulsions. On admission she had great dyspnoea, respirations 
60, pulse 132, temperature 104.2° F. ; face extremely pal] id, with a greenish tinge, 
but no jaundice ; no oedema or dropsy. The cardiac region was bulging, with 
heaving impulse reaching outside of the nipple to the sixth space, and a large area 
of cardiac dulness. There was a prolonged systolic apex-murmur ; a few rales at 
the base of the lung ; liver and spleen not enlarged ; a trace of albumen in the 
urine. Convulsions recurred, with squinting, contracted pupils, and almost com- 
plete unconsciousness. On the following day speech and consciousness returned, 
but the left side was completely paralyzed. The pulse rose to 158, respirations 56, 
temperature 103° F. She died on the sixth day, and the autopsy showed the peri- 
cardium firmly adherent, the heart greatly hypertrophied and weighing 12J ounces, 
the left auricle much dilated, its lining membrane opaque, and just above the aortic 
segment of the mitral valve was composed of thickened endocardium, with adherent 
lymph attached in polypoid masses, and sharply-cut ulcers owing to the breaking 
down of atheromatous-looking patches just above the root of the flaps at their 
junction. The mitral valve was greatly thickened and shortened, and polypoid 
vegetations were attached, but there was no ulceration on the flaps themselves ; 
infarcts were found in the kidneys, spleen, and right middle cerebral artery. 

Ulcerative endocarditis has the subjective symptoms of a septicsernic 
disease. There are rigors, followed by sweating, diarrhoea, high temperature 
at intervals, rapid and feeble pulse, and prostration. The liver and spleen 
may enlarge, the skin become sallow, and even hemorrhagic spots may appear. 
It is liable to be mistaken for typhoid fever, and when convulsions are present 
it has been diagnosed meningitis. The symptoms pointing to the heart, how- 
ever, if properly appreciated, will lead the practitioner to detect the true 
nature of the affection. The fact that ulcerative endocarditis complicates 
such diseases as diphtheria, rheumatism, and scarlet fever must be remem- 
bered, for they tend to obscure its real presence. 

The treatment of this formidable disease must be governed by the 
symptoms. As it is closely allied to septic diseases, such remedies as quinine 
and iron, stimulants, opium, highly nourishing foods, and pure air are chiefly 
useful . 



CHAPTER VI. 



CHRONIC ENDOCARDITIS. 



Acute rheumatic endocarditis is very liable to terminate in chronic 
disease of the valves of the heart of a most serious character. Sansom 
states that in rheumatism the endocardium is more vulnerable in the child 
than in the adult ; of the cases of acute and subacute rheumatism treated 
at a children's hospital where the patients were not admitted after twelve 
years of age, he found valvular disease, at the time of the patient's leaving 
the hospital, manifest in from 50 to 60 per cent. It has already been stated 
that the evidences of the presence of a rheumatic condition may be so obscure 
that it is often overlooked as a cause of valvular disease. It may occur in 






CHRONIC ENDOCARDITIS. 921 

the progress of scarlet fever and other infectious diseases, and even as a 
result of injuries. 

The lesion created is usually such a thickening of the mitral valves and 
retraction of their margins that in the systole the blood regurgitates into 
the left auricle. In other cases the curtains of the mitral valves become 
adherent to the orifice narrowed, so as to cause stenosis. Two conditions 
of the apparatus of the heart must be considered — viz. mitral inadequacy 
and mitral stenosis. 

1. Mitral inadequacy is attended by a reflex of blood into the left auricle 
in ventricular systole. The symptom most directly indicating mitral regur- 
gitation is a murmur heard over the apex of the heart during the systole 
of the ventricle. It is sometimes heard in the direction of the left axilla, 
and again under the angle of the left scapula. If this murmur is well 
defined and the child has the evidences of a rheumatic condition, present 
or past, the diagnosis of mitral inadequacy is quite certain. It is only when 
this murmur follows pericarditis, without any trace of rheumatism, that the 
doubt may be justified, for this murmur may be detected temporarily in such 
cases, and finally disappear. Sansom states that in a large majority of cases 
persistent systolic murmur at the apex indicates structural alteration of the 
valve or its attachments, but exceptions may occur in the condition of myo- 
carditis which accompanies pericarditis, and in the systolic murmur due to 
dilatation of the ventricles without any disease of the valves. The latter 
affection is very rare. 

The diagnosis of mitral insufficiency requires a careful inquiry into the 
preceding history of the patient with reference to open or latent attacks 
of rheumatism, and a recognition of the above symptoms. 

The treatment of mitral insufficiency is most important in its earlier 
stages. Every effort should be made to remove the conditions which aggra- 
vate it. for the progressive changes which naturally follow the initial lesion 
are destined, unless arrested, to result in completely incapacitating the heart. 
There is also a constant liability to a renewed attack of endocarditis or 
pericarditis, or both combined, which must be carefully guarded against. 

The first efforts made should be directed to securing rest and quiet. For 
a limited period the child should be confined to the room, and for the most 
part to the bed. All conditions which cause physical and mental unrest or 
excitement must be rigidly excluded. If there is much pain or distress in 
the region of the heart, warm poultices will give relief. If mustard is added 
to the poultice in such quantities as to cause redness of the skin without 
exciting the heart, the relief is more complete. The digitalis poultice is 
recommended by Sansom, thus : 

R . Digitalis-leaves, dried, 2 ounces ; 
Linseed-meal, 2 ounces ; 

Water, 1 pint. 

Boil the leaves with the water for ten minutes, then add the linseed- 
meal gradually, stirring constantly ; spread the mass on tow, and smear 
a little olive oil on the surface of the poultice. 

As the patient begins to improve gentle exercise may be allowed, but for 
a time not to 'the extent of increasing markedly the heart's action. The 
clothing next to the skin should be woollen and tightly fitting to protect 
against changes of temperature. Massage of the chest is useful when 
properly performed. 

The diet should be very nutritious, unstimulating, and easily digested. 
Milk should be freely given, and, if the stomach is disturbed, the milk 
should be peptonized. The sarco-peptones are readily digested. In cases 



922 LOCAL DISEASES. 

of feeble digestion or nausea and vomiting Sansom recommends nutritive 
enernata, made by shaking together in a bottle two ounces of warm milk 
with one ounce of cod-liver oil, or an egg with an ounce of hot milk and an 
ounce of cod-liver oil. These should be administered three times daily 
through a soft catheter well introduced. 

If there is any manifestation of the presence of rheumatic conditions, the 
citrate or acetate of potassium should be given. If the symptoms do not 
improve, sodium salicylate or salicin should be added, in from three- to ten- 
grain doses, in a mixture containing extract of liquorice. Of other remedies, 
cod-liver oil aids general nutrition and is usually readily taken by the patient. 
Sansom advises that it be given finely divided as an emulsion, and in doses 
of from twenty minims to one drachm three times daily : 1 

R . Cod-liver oil. 30 minims ; 

Pure glycerin, 10 minims ; 
Solution of lime or 

Mucilage of acacia, 1 fluidrachm. 

Iron in the form of the syrup of the phosphate, or mist, ferri comp., or 
the tartarate may be given according to indications. 

If the heart lesion progress and compensation does not occur, cardiac 
tonics will be required. Dyspnoea may become a troublesome symptom, 
when the tincture or infusion of digitalis is the best remedy. If it is not 
well borne on account of irritability of the stomach, caffeine may be substi- 
tuted, in the form of the citrate, in one- to three-grain doses. Sansom 
recommends convallaria majalis, the liquid extract, in from four to fifteen 
drops. He advises that cardiac tonics should be interrupted for a day after 
continuous administration for a week, for, though preliminarily increasing the 
renal secretion, after prolonged action they may diminish it. 

As the disease advances heart-sedatives must be employed to relieve rest- 
lessness and sleeplessness due to palpitation and distress in the precordial 
region. One of the simplest remedies for this purpose is bromide of potas- 
sium or sodium in two to ten grains. Chloral hydrate may be added to the 
bromide in two to four grains if the symptoms are severe and unrelieved by 
the latter remedy. In some cases opium must be substituted in the form of 
paregoric for young children and laudanum for older children. 

Dropsical effusions often occur, and they may take the form of oedema or 
of collections of fluid in cavities. In any case, they mark the progress of the 
disease in the increased embarrassment of the circulation. By careful atten- 
tion to the condition of the patient and the judicious use of remedies the 
effusions can frequently be removed. The skin, bowels, and kidneys are the 
chief means of eliminating the fluid. The skin is best acted upon by the hot- 
air bath, which may be readily extemporized with the simple apparatus now 
generally in use, or hot-water bags may be placed under the bed-clothes 
raised above the body on hoops. In some cases sweating may be induced by 
sponging with hot carbonate-of-soda solutions, and then wrapping the body in 
woollen blankets. The most useful cathartic for the removal of effusions is 
the compound jalap powder in five- to ten-grain doses. As a diuretic, digi- 
talis, properly combined, has the advantage of also sustaining the heart. 
Sansom gives the following combination every four hours : 



B. 


Tinct. digital., 


*Uj-v ; 




Spiritus aetheris nitrosi, 


rr^v-xx ; 




Tinct. scillae, 


niiij-x ; 




Potass, acetat, 


gr.nj-x ; 




Decoct, scoparii, 


3J- 1V - 



1 Cyclopcedia Lis. Chil. 






DISEASES OF THE VESSELS. 923 

By these means great, and often complete, temporary relief may be ob- 
tained by the removal of the effusion. If the kidneys and skin fail to 
respond to remedies, as sometimes happens, tapping of cavities where the 
fluid has accumulated in large quantities or the puncture of cedematous limbs 
must be practised. 

2. Mitral stenosis consists in a thickening of the tissues around the 
auriculo-ventricular orifice, which obstructs the passage of the blood from 
the auricle to the ventricle. At first the vegetations, already noticed, slightly 
diminish the orifice ; then follow thickening of the folds of the mitral valve, 
extending also to the cords, and at length the usual condensation of all the 
tissues about the orifice, attended by a constant narrowing of the opening, 
which may preserve the rounded form or be reduced to a mere slit. The 
cavity of the left auricle becomes enlarged and its walls thickened, but the 
left ventricle remains unaffected. The right auricle and ventricle become 
necessarily dilated from the engorgement which exists. 

The evidences of the existence of mitral stenosis are found (1) in the 
antecedent history of rheumatic attacks ; (2) in the existence of an increased 
area of dulness on the right side of the heart, due to the dilatation and en- 
gorgement of the right cavities of the heart ; (3) a thrill felt over the apex 
of the heart, which suddenly ceases when the beat or pulse occurs ; (4) a 
murmur, varying in its character, which also suddenly ceases when the apex 
impinges upon the chest ; (5) the first sound is short and sharp. 

The diagnosis must depend upon an accurate observation of the above 
symptoms and others more obscure. This systolic murmur may finally be 
associated with a presystolic murmur, and the latter may even, in some cases, 
supersede the former. Embolism of a cerebral artery may occur, indicating 
the escape of particles from the vegetations on the valve. Epilepsy and 
chorea have developed in many cases. 

The treatment must be conducted on the same principles as have been 
given for mitral insufficiency. 



CHAPTER VII. 

DISEASES OF THE VESSELS. 

The arteries are rarely affected by degeneration in childhood. The 
aneurysms which occur under the age of twenty, if not of traumatic origin, 
are due rather to embolism resulting from pre-existing endocarditis. In 15 
cases collected by Parker there were but 2 cases in which the arteries were 
diseased, and in but 2 cases was the heart free from disease. One boy, aged 
twelve, had a femoral aneurysm, with old hip disease on the opposite side. 

Keen 1 added to Parker's collection 11 cases. In 3 cases aneurysm of the 
arch of the aorta was found, and in 1 of these the child was still-born. 
Madrazo 2 has reported a case of popliteal aneurysm in a boy aged fifteen 
years, which ruptured into the knee-joint. 

Aneurysm of the cerebral arteries is more common in children than of the 
arteries in any other part. It is almost universally associated with vegeta- 
tion on the valves of the heart, and hence is embolic in its origin. 

Traumatic aneurysm is not infrequent in boys, and is caused most fre- 
quently by stab-wounds. 

1 Medical News, 1887. 2 L' Echo med., Toulouse, 1SSS. 



924 LOCAL DISEASES. 

The treatment of aneurysm of the arteries of the extremities in the 
child does not differ essentially from the treatment of the same individual 
disease in the adult. In general it may be assumed that in the child asepsis 
is of the first importance ; the ligature of the affected artery will be prefer- 
able to other methods of treatment ; in the selection of the ligature catgut 
or silkworm gut is better than silk ; the ligature need not be applied so 
tightly as to rupture the internal coat ; the ligature should be buried by 
firmly closing the wound. 

Naevus. 

Naevi are, for the most part, congenital formations. They may be simple 
maculae, an excess of pigment ; moles ; an enlargement of the tissues of the 
skin, port-wine stains ; fire-marks, collections of dilated capillaries ; vascular 
tumors, consisting of masses of large vessels or cavernous sinuses filled with 
blood. 

The maculae, moles, and similar mother's marks are unimportant, as they 
are only blemishes or disfigurements. They may be removed by excision or 
by escharotics, as nitric acid, Vienna paste, or chloride of zinc. 

The naevi are properly classified as angiomata, hsemangiomata, or tumors, 
chiefly made up of blood-vessels, some of which are new-formed and others 
are pre-existing vessels, more or less altered by dilatation or thickening of 
their walls. Ziegler gives the following subdivisions : 

1. Simple angioma (telangiectasis or simple erectile tumor), a structure 
made up of some normal basis-tissue, containing an abnormal number of dis- 
tended and altered veins and capillaries. They chiefly occur in the skin at 
places where foetal clefts have been closed. The color is bright red (straw- 
berry mark) or livid (port-wine mark). They consist essentially of localized 
dilatations of new-formed or pre-existing capillaries. The dilatations are fusi- 
form, cylindrical, sacculated, or spherical, combined in all possible ways. 
There are several forms. In one there are wide cavities connected together 
by normal or but slightly dilated capillaries, the walls of which are not per- 
ceptibly thicker than the normal. In another form the mass consists of 
dilated capillaries whose walls are considerably thickened and the basis- 
tissue is thrust out of sight. In still another form, the venous or varicose 
tumor, the small veins instead of the capillaries are chiefly thickened and 
dilated. 

2. Cavernous angioma is distinguished from the simple angioma in this, 
that the tubular form of the vessels is more or less lost, and the tumor is 
made up of variously-shaped cavities separated by fibrous septa. These 
tumors are commonly seated in the skin and may be congenital, or may be 
developed from simple angiomata by continued dilatation of the already 
dilated vessels. 

Though nasvi may appear in nearly every region of the body, they are more 
frequently met with on the scalp, face, lips, eyelids, and cheeks. They may 
appear on the labia and about the anus. 

The diagnosis of naevi is easily made. The color indicates the class of 
vessels principally involved. If the color is bright red, the small arteries and 
capillaries are chiefly involved ; if it is dark or purplish in color, the veins 
compose the greater part. The simple angiomata are scarcely elevated above 
the skin, while the cavernous variety may form a considerable tumor. 

The prognosis depends upon the variety of angioma present. The 
simple forms often remain stationary for a time and then fade away. Some 
disappear after an injury of the part, and still others fade after an exanthem- 
atous disease or even after whooping cough. Others enlarge for a time and 



DISEASES OF THE VESSELS. 



925 






then disappear, while some have an intermittent growth. But a certain 
number take on active growth from the first. The method of cure, when it 
is spontaneous, may be by a process of shrinking of the vessels until they 
are merely fibrous cords ; or thrombosis may occur ; or the degeneration 
may be calcareous. Cysts may form, owing to the closure of the spaces, 
especially during the progress of degenerative processes. The cavernous 
angioma may remain long as a mere disfigurement, but there is a constant 
liability that it will take on active enlargement. 

The treatment inust be governed by the nature of the angioma. The 
simple variety requires no treatment when it is so situated that it does not 
disfigure and remains inactive. If it is on exposed parts, as the face, an 
attempt to obliterate it may be made. 

Naevi are sometimes as large as a pin's head, and again as a hempseed ; 
some are moderately thick, others scarcely rise above the level of the skin ; 
as a rule, this proliferation of vessels does not extend beyond the sub- 
cutaneous cellular tissue ; they frequently not only cease to enlarge, but 
undergo a gradual contraction and obliteration ; hence the propriety of treat- 
ing them at first with mild remedies, as pressure, applications of collodion, 
vaccination. If more radical measures become necessary, inject persulphate 
of iron, using precautions by pressure around the growth to prevent the 
entrance of coagula into the circulation, or pass red-hot needles under it at 
several points and secure a slough. Strangulation of the mass by subcuta- 
neous ligature, when the growth is accessible, is adapted to the larger naevi, 
and may be applied in many ways, as follows : (1) The single ligature, strong 
whip-cord (Fig. 247), is carried around the tumor by entering it at one point 
and carrying it as far as possible round the base, then emerging and re-enter- 
ing at the same puncture, and is carried around another portion until it 
reaches the point of first entrance, where the two ends are firmly tied ; (2) or, 
if the growth is too large, the ligature may be carried, double, under the 



Fig. 247. 



Fig. 248. 




Subcutaneous ligature of nsevus (Holmes). 




Ligature of a mixed nsevus : a pin is 
passed through the growth, and a 
needle at right angles to the pin is 
armed with a double ligature. 



tumor, and then each section may be carried round the half and tied under 
a pin (Fig. 248). For a large naevus the following knot may be made : Pass 
the needle under the centre of the tumor (Fig. 249) ; divide one thread near 
the needle ; pass the other end of the ligature into the needle's eye ; now 



926 



LOCAL DISEASES. 



enter the needle at a quarter of the circumference, and pass it under the 
base at right angles to its former direction ; before tying the ends make a 
lunated incision between each puncture into which the ligature sinks ; finally, 
tie the opposed ends (Fig. 250). 

If the tumor is elongated in form, the ligature may be applied as follows 



Fig. 249. 



Fig. 250. 



Fig. 251. 






Ligature of nsevus : the other end of 
the divided thread passed into the 
needle's eye, and the needle passed 
through at right angles to its for- 
mer direction. 



Incisions for ligature. 



An elongated nsevus. 



(Fig. 251) : Pass a double ligature under its base from side to side ; color the 
end of one ligature white and the other black ; leave each loop long, the 
whole ligature being of great length ; divide the white loops on one side and 
the black on the other, and tie the pairs of white and black strings tightly : 
the skin is destroyed by this method. 

The elastic ligature has been successfully used thus : Select straight needles 
without cutting edges, threaded with common band elastic of pure gum rubber, 
and pass subcutaneously beneath one side of the growth in 
succession, each successive needle with its ligature entering 
at the point of exit of the last one. 



Fig. 252. 



The cavernous tumor must be destroyed by (1) ex- 
cision, when the growth is large, the line of incision being 
quite external to the capsule ; (2) injection of persulphate 
of iron, in small quantities, when the tumor is small and 
not amenable to other remedies, as on the face, great care 
being taken to compress the vessels around the tumor to 
prevent the escape of the fluid into the general circulation. 
Xsevi of the lips (Fig. 252) require different treatment 
according to the amount of substance involved. When 
pendulous from the margin the double or quadruple liga- 
ture may be used. 

Electrolysis is a most effective method of treating 
naevi. The needle should be very slender and the battery 
twenty cells. First apply the needle to any vessels ; then introduce it at 
several points ; repeat the operation in one week. 




Large nsevus of up- 
per lip, side view. 



SECTION VI. 
DISEASES OF THE GENITO-UKINARY ORGANS. 






Infarctions of uric acid or the urates are very common in new-born 
infants. They are seen, if an opportunity of examining the kidneys occurs, 
as yellowish-red lines in the tubules or lying in the pelvis of the kidney, 
forming small yellowish granules. As they are washed away by the urine, 
we often find them upon the diaper. The irritation produced by these infarc- 
tions sometimes causes painful micturition. Children a few months old often 
fret or cry from pain during urination in consequence of the irritating action 
of the uric acid, while in the intervals between the passing of water they 
may or may not be free from suffering. Perhaps they pass only a few drops 
of urine with straining, and in it we find crystals of uric acid or the urates. 
Urine highly acid from the presence of this substance causes a burning pain 
in the urethra, and sometimes redness not only of the urethra, but even of 
the labia over which the urine flows. Although infants perhaps suffer most 
from this cause, the same condition not infrequently occurs in older children. 
Their urine, previously normal, becomes unduly acid from some error in feed- 
ing or in the digestive process, and uric-acid crystals or concretions form. 
An exaggerated secretion of mucus occurs from the surface of the bladder 
or from the urinary canal in consequence of the irritation produced by the 
acid, and sometimes pus-cells are also seen under the microscope mixed with 
the mucus. 

The state of the urine described above should be at once rectified, for it 
furnishes the conditions in which calculi form either in the pelvis of the kid- 
ney or in the bladder. Urine unduly acid and irritating probably at first 
causes catarrh of the delicate membrane lining the tubules and pelvis of the 
kidneys, and if the irritation be sufficiently severe the catarrh extends along 
the ureters to the bladder, causing a degree of cystitis. Now, a catarrh of 
the pelvis of the kidney or the bladder greatly increases the tendency to the 
formation of calculi, since the crystals become imbedded in the mucus, which 
serves to agglutinate them. Uric acid, when so abundant in the urine as to 
cause symptoms, should be at once treated and the acid neutralized by an 
alkali. The liquor potassae, employed as recommended in our remarks on 
the treatment of Enuresis, is the best alkali for this purpose. For an infant 
of one year, two drops sufficiently diluted in mucilage will be sufficient, 
repeated in three or four hours. 

The various forms of nephritis have been considered in connection with the 
diseases with which they occur, as scarlet fever and diphtheria. 

Enuresis, or incontinence of urine, is a common and troublesome infirmity 
in children. It occurs both in boys and girls, but is more common in the 
former than in the latter. In many children it dates back to infancy, but 
others have a respite from it in the years immediately succeeding infancy 
until the sixth or seventh year, when it returns. It may be diurnal as well 
as nocturnal, interfering seriously with the comfort of the child and render- 
ing his schooling inconvenient ; but the annoyance which it causes is coni- 

927 



928 LOCAL DISEASES. 

monly most at night, and it is for nocturnal enuresis that the physician is 
most frequently consulted. The child may pass his urine in bed every night, 
or even more than once each night, or there may be occasional nights of 
immunity. 

The bladder consists of three concentric coats : 1. On the outside, the 
peritoneal, which covers the posterior, the superior part of the lateral, and 
the anterior aspects of the organ ; 2. The muscular, which chiefly concerns 
us at present, and which consists of two layers — the one external, the fibres 
of which have a general longitudinal direction ; the other internal, whose 
fibres are circular. The circular fibres become more abundant, producing 
greater thickness of this layer, at the urethral orifice, and they extend a dis- 
tance over the urethra. This increase in the number of circular muscular 
fibres at the urethral orifice constitutes the sphincter vesicae. The fibres in 
the muscular coat of the bladder are unstriped, and are not under the control 
of the will. 

A second sphincter, which aids materially in the retention of urine, is 
formed by the compressor urethrse. This muscle, arising by aponeurotic 
fibres from the ramus of the pubes, surrounds the whole membranous por- 
tion of the urethra, extending from the prostate to the bulbous portion. The 
compressor urethrse is a striped muscle, and its action is therefore controlled 
by the will. Certain accessory muscles influence the retention as well as the 
expulsion of urine — to wit, the levator ani, accelerators urinse, and the abdom- 
inal muscles. 

Nerves. — The muscular coat of the bladder receives its nerves from the 
hypogastric plexus, which belongs to the sympathetic system, although fila- 
ments enter the plexus from the spinal system. The innervation of the blad- 
der is therefore twofold, that derived from the sympathetic system predom- 
inating over that from the spinal system, as shown by the relative number of 
filaments from the two sources. According to Belfield, the spinal centre of 
the motor nerves of the bladder is in the vicinity of the third lumbar verte- 
bra ; but Budge, in his experiments on rabbits, locates it in this animal in 
the vicinity of the fourth lumbar vertebra. The spinal centre of the nervous 
supply of the bladder, says Coulton, " is connected with the brain by a 
strand of fibres which may be traced from the cerebral peduncle along the 
anterior columns of the spinal cord." The neck of the bladder, including 
the sphincter vesicae, derives nervous fibres directly from the anterior or 
motor roots of the third, fourth, and fifth sacral nerves, and it is more 
abundantly supplied with nervous filaments than is the muscular coat of the 
organ. That the sphincter vesicae is under the control of the will is there- 
fore apparent from the anatomical characters, since a strand of fibres con- 
nects the peduncles with the motor centre of the bladder in the spine, and 
this centre connects with the sphincter through the spinal nerves. In nor- 
mal urination the sphincter is relaxed by the volition of the individual, while 
the muscular coat of the organ, being under the control of the sympathetic 
system and involuntary in its action, expels the urine as soon as the sphinc- 
ter is open. 

The pudic nerve also sustains an important relation to the function of the 
bladder. Arising from the sacral plexus, it is distributed " to the base of the 
bladder, the prostate, the integument of the penis, scrotum, and perineum, 
the urethral muscles and mucous membrane, and the sphincter of the anus ; 
in the female, the uterus, vagina, and vulva are supplied by branches of the 
same nerve." Knowledge of the distribution of the pudic nerve enables us 
to understand the manner in which disease or abnormal conditions of the 
genital organs and anus disturb the functions of the bladder. Irritation 
of the inferior branches of this nerve affects the action of the superior 



DISEASES OF THE GEXITO-URIXARY ORGAXS. 929 

branches, or those which supply the base of the bladder and the urethral 
muscles, so as to produce in certain patients dysuria or incontinence, or 
both. 

Etiology. — In all cases the urine should be examined, since the cause 
of the enuresis is often discovered in the deviations in it from the normal 
state which are apparent on inspection. The chief causes may be grouped 
as follows, but often two or more of them are present in the same case : 

1. Too great acidity of the urine. The urine in its normal state is acid 
from the presence of the acid phosphate of sodium (Robin), but in certain 
conditions the acidity becomes so great that the urine is unduly stimulating 
to the surface of the bladder. Now, stimulating or irritating urine causes 
the bladder to contract, just as an irritating substance in the intestines 
increases the peristaltic and vermicular movements of this tube. Exces- 
sive acidity of the urine is commonly due to the presence of uric acid, 
resulting from decomposition of the urates ; but in certain conditions lactic 
and hippuric acids, resulting from faulty digestion, appear in the urine 
(Robin) ; urine unduly acid renders its retention difficult, except in mod- 
erate quantity, so that enuresis results. 

2. Increased quantity of urine. This sometimes occurs from the free 
use of liquids, as of water or milk. Renal disease, attended by an exag- 
gerated excretion of urine, sometimes produces enuresis. Henoch 1 says : 
" I would advise you never to omit an examination of the urine, because 
cases of diabetes mellitus and chronic nephritis are known which were first 
manifested by nocturnal incontinence." 

3. A vesical calculus. This is an infrequent cause, but when present it 
is likely to produce both diurnal and nocturnal enuresis. If micturition be 
frequent and painful by day and by night, if the urine contain a large 
amount of mucus or muco-pus so as to render it turbid, and if the dysuria 
and frequent urination be not soon relieved by treatment, a calculus is prob- 
ably present. In such cases the bladder should, of course, be sounded by 
the proper instrument to render diagnosis certain. 

4. The muscular coat of the bladder may have an exaggerated contractile 
power in itself, and not imparted to it by any extraneous stimulating agency. 
The surrounding conditions may be normal, while the bladder is hypersensi- 
tive, so as to contract with undue energy by ordinary stimulation. The fault 
is in the bladder itself, whose functional activity is in excess ; this appears to 
be the most common cause of enuresis in children. It is the condition of the 
bladder which Trousseau had in mind when he wrote : " I repeat that the 
nocturnal incontinence of urine is a neurosis, and I now add that it is a neur- 
osis manifesting itself by excessive irritability of the bladder ; in fact, the 
immediate cause of incontinence is this excess of irritability in the muscular 
fibres of the bladder." As Bretonneau pointed out, children with enuresis 
from this cause habitually pass urine in a full and rapid stream, and therefore 
in less time than other children, showing that the contractile power of the 
muscular coat is in excess. From the fact that belladonna relieves so many 
patients, we infer that irritability of the muscular coat is a common cause 
of enuresis in children, since this agent acts by diminishing muscular con- 
tractility. 

5. Weakness of the muscular fibres which constitute the sphincter of the 
bladder. Diminished tonicity of the sphincter muscles does not occur, or it 
occurs very rarely, in those who have had previous good health and are robust. 
Ordinarily, children affected by enuresis from this cause are in habitual ill- 
health. They have had long and prostrating sickness, which has diminished 
muscular tonicity, or they have local disease in the spine or in the course of 

1 Diseases of Children, p. 257. 
59 



930 LOCAL DISEASES. 

spinal nerves, which has impaired the innervation of the sphincter. Some- 
times incontinence of feces is also present, and examination of the sphincter 
ani by introducing the finger shows that its contractile power is insufficient. 
We infer the presence of atony of the sphincter vesicae from the atony thus 
easily discovered of the sphincter ani. As an example of enuresis from atony 
of the sphincter vesicae we may mention the case of a boy of thirteen years 
who had " a flat, doughy tumor " at the lower end of the dorsal vertebrae, in 
the middle of which a deficiency in the bony arch which covers the spinal 
cord was detected by the fingers, showing that the tumor was a spina bifida 
containing a considerable amount of adipose and granulation tissue. The 
congenital deficiency in the spinal column, and consequent injury of the 
spinal cord, had produced incontinence of both urine and feces. 

6. We have already, in speaking of the distribution of the pudic nerve, 
alluded to the fact that enuresis in children is not infrequently produced 
through reflex action by disease or an abnormal condition external to the 
bladder in parts which receive their nerves from the same source as the 
bladder. Henoch says : " Occasionally congenital phimosis, stricture of the 
urethra, irritation of ascarides, fissure of the anus, onanism, or vulvitis can 
be detected, upon the removal of which the enuresis ceases." Trousseau 
relates the case of a young man of seventeen years who from childhood had 
been in the habit of wetting the bed two or three times every night. After 
unsuccessful trial of belladonna, strychnia, and mastich, it occurred to Trous- 
seau that the infirmity might be due to congenital phimosis, and accordingly 
Professor Jobert circumcised him. With the exception of three consecutive 
nights he was entirely relieved of enuresis during his subsequent stay of 
nine months in the hospital. In dispensary practice in New York City we 
find preputial adhesions, with the accumulation of smegma between the glans 
and foreskin and more or less balanitis, a common cause of disturbed func- 
tion of the bladder. The dysuria and enuresis cease when the adhesions are 
divided by the probe, the smegma removed, and the preputial inflammation 
or irritation has abated. 

7. A psychical cause, to which Bartholow alludes. The patient dreams 
that he is in a convenient place for urination, the desire of which is impressed 
on his thoughts, and awakens to find that he has urinated in bed. Since the 
action of the bladder is largely under the control of the will, a strong will 
or determination, if the patient be not too sound a sleeper, does exercise a 
controlling action over the bladder even during sleep. We sometimes observe 
this effect of will-power in the fact that the patient breaks the habit of 
enuresis through a sense of shame or by a determination to avoid the dis- 
grace. Thus one writer mentions the case of a girl in whom severe flogging 
by her mother put a stop to the habit, and patients sleeping away from home, 
as when visiting among friends or at a boarding-school, sometimes break the 
habit through an effort of the will. The sense of profound shame which the 
infirmity produces thus enables certain patients to control the action of the 
bladder even in sleep. The state of the mind should therefore be considered 
as an element both in the causation and cure of the infirmity. 

8. Malformation of the bladder or its appendages. These are of various 
kinds. Some of them are of such a nature that cure of the enuresis is diffi- 
cult or impossible. Thus, Thomas U. Madden, M. D., F. R. S. C. E., relates 
the case of a young lady who had been treated by different physicians in 
various localities with belladonna, iron, vesication of sacrum, and the other 
usual remedies, without the least benefit. The dribbling of urine was con- 
stant day and night, so that she was debarred from school and ridiculed and 
avoided by her associates. She was placed under chloroform, and her blad- 
der was found to have the power to retain a considerable amount of urine. 



DISEASES OF THE GEXITO-TJRINARY ORGANS. 931 

Pursuing the examination, Dr. Madden found that the urine dribbled from a 
small orifice about half an inch above the meatus urinarius and covered by 
rugae of the mucous membrane. A No. 1 catheter was introduced its entire 
length through the opening, so that, in the opinion of Dr. Madden, there was 
malposition and elongation of the right ureter, which, instead of emptying 
into the bladder, discharged the secretion of the right kidney upon the vulva. 
In malformations like the above, as well as in ectopia vesicae, recto-vesical or 
vesico-vaginal fistula, the result of abnormal foetal development, the urine 
obviously dribbles constantly and from the moment of birth. In perpetual 
lifelong dribbling a malformation or congenital defect should be suspected, 
and is probably the cause. 

Prognosis. — The prognosis depends on the cause or causes of the enure- 
sis. Most of the causes are of such a nature that they can be removed, and 
the majority of patients can therefore be cured by appropriate remedies. 
Enuresis due to irritating properties in the urine, to irritation or inflamma- 
tion in the genital organs or rectum, and that due to exaggerated tonicity 
of the muscular coat of the bladder, can be for the most part readily cured 
by appropriate measures, while that resulting from structural disease of the 
spinal cord or from malformations in the urinary tract is least amenable to 
treatment. 

It is the common belief that those epochs in life which produce a decided 
change in the individual, as puberty or marriage, are likely to effect a cure 
in cases previously obstinate. This opinion is to a certain extent founded on 
fact. The development of the sexual organs at puberty seems to render the 
bladder less irritable and more retentive in some patients. Cases are also 
related, as one by Trousseau, in which incontinence ceased with marriage and 
pregnancy. But treatment in the ordinary form of enuresis should not be 
deferred in the hope that time and physical changes will effect a cure, for 
this belief is likely to be illusory. 

Treatment. — The physician asked to prescribe for a case of enuresis 
should carefully examine the patient in order to ascertain the cause. Since 
the most common cause is irritability of the bladder, whether inherent in the 
bladder itself or imparted to it by the stimulating properties of the urine, 
the urine should be rendered as bland and unirritating as possible. This 
is best accomplished by rendering it neutral. Excessive acidity of the urine, 
so common a cause of enuresis, is promptly removed by the liquor potassae 
administered in doses of a few drops largely diluted. I have found it a safe 
and efficient remedy in the treatment of this infirmity when the bladder is 
unduly irritable. If, therefore, in the examination of a case we discover no 
cause of the incontinence except an exaggerated contractile power of the 
bladder, and the urine is acid, from three to five drops of the liquor potassae 
should be given three or four times daily in a wineglassful of gum-water 
until litmus-paper shows that the urine is neutral, and its neutral state 
should be maintained. 

In belladonna we possess an agent which diminishes the functional activ- 
ity of the bladder when the latter is in excess. It diminishes the contrac- 
tile power of the muscular fibres, and its use is therefore indicated in the 
class of cases which we are now considering. In this country the tincture 
of belladonna is more commonly employed than the extract, which is used 
in Europe, especially in continental Europe, and if obtained from a good 
laboratory its action is as certain as that of the extract, while its dose can 
be better regulated. Five drops of the tincture may be given every evening, 
or, if the enuresis be diurnal as well as nocturnal, every morning and even- 
ing, to a child of five years, and the dose be increased by one drop every 
second day if improvement do not occur and physiological effects are not 



932 LOCAL DISEASES. 

produced, until the dose is doubled or even trebled. If the enuresis be 
relieved, or if, without its relief, physiological effects be observed, as dry- 
ness of the fauces, cutaneous efflorescence, or dilatation of the pupils, the 
dose should not be increased. When belladonna produces the desired effect, 
it is no doubt best to continue its use for some weeks in the dose which is 
found to be effectual, and then to diminish the number of drops gradually. 

Trousseau, who, as we have seen, considered enuresis in most cases a 
neurosis, highly extolled the treatment by belladonna, believing it the most 
effectual of all methods of cure. He prescribed the extract of belladonna, 
gr. 1, or the sulphate of atropia, gr. yl^, but he did not state the age of his 
patients. The dose was increased if necessary, and whatever dose he found 
sufficient to give relief he administered once daily for three, four, or five 
months, after which it was gradually diminished, but it was not discontinued 
until after the lapse of two to ten months. By this treatment Trousseau 
states that a majority of his cases were signally benefited, and not a few 
were entirely relieved. The following case, which recently occurred in my 
practice, indicates the mode of treatment in enuresis when it results from the 

cause which we are now considering : L , aged eleven years, male, had 

diurnal and nocturnal enuresis, which seriously interfered with his comfort 
and rendered him an object of aversion and ridicule among his schoolmates. 
He had previously taken belladonna and other remedies without improve- 
ment. His urine was found highly acid. Five drops of liquor potassae were 
ordered to be given in water three or four times daily, and the tincture of 
belladonna, to which he was accustomed, was administered in nine-drop doses 
three times daily, to be increased, if need be, to fourteen or fifteen drops. 
The liquor potassse, in the dose mentioned, immediately rendered the urine 
neutral, and the enuresis from that time ceased. The treatment recommended 
above, of rendering the urine as little irritating as possible by neutralizing it, 
aided by belladonna, which diminished the contractility of the muscular fibres, 
cured the infirmity, which had been most troublesome and tedious. 

If the enuresis be due to an abnormally large secretion of urine, the 
liquid ingesta in the latter part of the day should be restricted. If it be 
found that the increased flow is due to diabetes or chronic nephritis, the enu- 
resis, though an unpleasant symptom, is comparatively unimportant, and the 
grave disease which causes it requires chief attention. The quantity of 
urine may be diminished in diabetes mellitus by the use of proper food, and 
in diabetes insipidus by ergot. 

Enuresis due to a vesical calculus is associated with symptoms, as we 
have stated above, which indicate the presence of stone, such as painful 
micturition, which may awaken the patient at night, and thus prevent the 
accident of which we are treating. Urination more frequent and painful in 
the daytime than at night, occasional interruption in the stream of urine 
from the impediment, pus, perhaps blood and an increased amount of mucus, 
in the urine, indicate the presence of a stone. Fortunately, the calculus is 
easily detected by sounding, and by the present improved instruments it can 
be crushed and removed, or it can be removed by lithotomy, which in the 
opinion of some is less dangerous, and is preferable to crushing when the 
patient is a child. 

As we have stated above, the physician should always examine parts con- 
tiguous to the bladder, as the genital organs and rectum, in order to ascer- 
tain if there be any source of irritation in them which may produce irrita- 
bility of the bladder by reflex action. In some instances, as we have seen, 
enuresis rebellious to ordinary treatment ceases when the irritation in parts 
contiguous to the bladder is removed. Phimosis, preputial adhesions, the 
accumulation of smegma between the foreskin and glans, with more or less 



DISEASES OF THE GEXITO-URIXARY ORGANS. 933 

balanitis produced by the foul products, and vulvitis, or ascarides, should, if 
present, receive treatment, and with the removal of the irritating cause the 
enuresis will probably cease. 

Cases in which preputial irritation produces an irritable state of the blad- 
der are not infrequent among the poor of New York, whose habits are fre- 
quently degraded and filthy, and the treatment consists in dividing adhesions 
of the glans to the foreskin, cleaning away the smegma, and using a sooth- 
ing ointment. The foreskin can, with few exceptions, be sufficiently stretched 
for this purpose, so that incision (or circumcision, which is frequently per- 
formed in these cases) is unnecessary. 

If the enuresis be due to atony of the sphincter, a remedy is required 
which acts very differently from belladonna. If weakness of the sphincter 
be the cause, the indication is obviously to increase its tonicity, and the two 
medicines which have been most successfully employed for this purpose are 
nux vomica (or its active principle strychnia) and ergot. We have stated 
that the sphincter is more abundantly supplied with nerves than is the mus- 
cular coat of the bladder, so that those agents which restore innervation, and 
thereby increase muscular tonicity, act upon the sphincter more powerfully 
than upon the muscular coat. Ergot appears to exert a similar action, 
though perhaps less in degree, upon the sphincters of the bladder and anus, 
to that which it exerts upon the uterine muscular fibres. 

We can obtain a clearer idea of the effect of therapeutic agents upon 
paresis of the sphincter vesicae by observing their action in paresis of the 
sphincter ani, for these two sphincters suffer a loss of power from the same 
causes, and recover it by the use of the same agents. 

In a very instructive paper on incontinence of feces, published by Dr. 
George B. Fowler in the American Journal of Obstetrics for October, 1882, 
two cases are detailed, showing unmistakably the beneficial action of ergot in 
increasing the tonicity of the sphincter ani ; and the same treatment is indi- 
cated for urinary incontinence when it arises from a similar cause. A child 
of seven years, in the practice of Dr. Fowler, had been closely confined to 
his studies, with probably some deterioration of his health, when fecal incon- 
tinence commenced. The tonicity of the sphincter ani on examination with 
the finger did not seem much impaired. Nevertheless, it was so increased by 
ten-drop doses of the fluid extract of ergot that the incontinence was relieved. 
The second patient, an anaemic girl of thirteen years, had been under treat- 
ment with iron and other tonics without benefit to the fecal incontinence. 
Her flesh was flabby and surface cool, and, which is interesting to remark as 
throwing light on the condition of the vesical sphincter when it lacks toni- 
city, a lack of resistance in the anal outlet was very apparent to the touch. 
A mixture containing 15 minims of the fluid extract of ergot and grain -j-jL- 
of strychnia was given three times daily. At the end of the first week she 
had only two recurrences of the trouble, and in three weeks was cured. 
Four months afterward, although she had been taking quinine and iron after 
the discontinuance of the ergot, a partial relapse occurred, and a suppository 
of five grains of ergotin, with butter of cocoa, was employed morning and 
evening. Immediate relief followed, the tonicity of the sphincter was 
restored, and the suppositories were discontinued after two weeks. The 
beneficial effects of ergotin in weakness of the sphincters is shown by these 
cases. Enuresis from weakness of the sphincter vesicae could not have been 
better treated than by the same remedies which relieved the fecal inconti- 
nence in these two patients. 

A considerable number of medicines which are now seldom used have 
been employed with more or less success for enuresis. According to 
Bouchut, M. Bibes was the first who prescribed nux vomica. The patient 



934 LOCAL DISEASES. 

was a soldier who had both urinary and fecal incontinence, and was cured of 
the weakness of the bladder in five days. Nux vomica is employed instead 
of strychnine, as its use involves less danger. Mondiere prescribed this 
agent in combination with the black oxide of iron in the following formula : 

R. Extractis nucis vomicae, gr. vj ; 

Ferri oxidi magnetici, 3j. 

Ft. pil. No. xxiv. 
Take one pill three times daily. 

Although we accept the statement of Bouchut that strychnia is an 
u extremely dangerous " remedy for enuresis if the patient be under the 
age of four or five years, yet over that age it can be safely prescribed as 
an adjuvant to the ergot in proper dose and with proper precautions. A 
small dose, repeated after three hours, is obviously safer than a larger dose 
at longer intervals. 

Among the remedies not yet mentioned which have been successfully 
employed in certain cases, the tincture of cantharides requires notice. In 
large doses this drug causes strangury, but in small doses it produces 
such irritation or stimulation of the surface of the urethra as to increase 
the contraction of the sphincter and awaken the patient when the urine 
presses upon the urethral orifice, which is rendered sensitive by this agent. 
Cantharides is an unpleasant remedy, and it is not much employed of late 
years ; probably the benefit from its use is not usually permanent. A child 
of five years can take four or five drops, largely diluted with water, three 
times daily, and the dose should be gradually increased until there is some 
evidence of its effect on the outlet of the bladder. 

Cubebs, recommended by M. Dieters, the various vegetable tonics and 
astringents, iron, creasote, and many other remedies, have fallen into dis- 
repute and are now seldom used. Sometimes certain combinations of rem- 
edies give prompt and entire relief. Eustace Smith says: "I have lately 
cured a little girl, aged four years, who had resisted all other treatment, with 
the following draught, given three times daily : 



"K. Tinct. bellad., 


&j; 


Potas. bromidi, 


gr. x; 


Infus. digitalis, 


3y ; 


Aquae, 


ad ^ss. — Misce. 


Ft. haustus." 





The tincture of belladonna of the British Pharmacopoeia has about half 
the strength of that employed in the United States ; but even with this 
allowance I would not dare to prescribe so large a dose of this agent, 
unless smaller doses were first used and tolerance of the remedy demon- 
strated. Of the tincture of belladonna of the U. S. Pharmacopoeia ten min- 
ims would be a large dose. 

Local treatment has been attended by a degree of success. The neck of 
the bladder and the urethra have been cauterized by the nitrate of silver 
applied by the porte-caustique of Lallemand, with some relief of the enure- 
sis, at least so long as the soreness remained. Baths and douches of cold 
water have also been used by many physicians, some of whom, as Under- 
wood, Baudelocque, Guersant, and Dupuytren, state that they have obtained 
good results. This treatment is most beneficial in those cases in which the 
sphincter is relaxed. 

Since the causes of enuresis are numerous, and in many instances cannot 
be fully recognized at first, the following prescription has been found useful 
in the Out-door Department at Bellevue, especially in the beginning before 









DISEASES OF THE GENITO-URINARY ORGANS. 935 

an exact diagnosis of the cause is made. The prescription is for a child of 
five years : 

R. Sodii benzoat., 

Sodii salicylate, da, gij ; 
Tine, belladonna?, fgij ; 

Aquae purae, f^iij- 

Give one teaspoonful two or three times daily. For a child of five years. 

In certain patients the advice of Trousseau may be followed, that the 
patient in the daytime resist the inclination to pass urine so long as it does 
not greatly increase his or her discomfort ; by this means greater tolerance 
of the presence of urine in the bladder is produced. 

Calculi ; Dysuria ; Cryptorchia. — We have seen, in our remarks on Uric- 
acid Infarctions, how calculi may form in the pelvis of the kidney, first as 
small concretions, and how, descending to the bladder, they may become 
nuclei which gradually increase by accretions to their surfaces, or they may 
form primarily in the bladder. A vesical calculus is not very infrequent, 
even in the young child. Its presence is manifested by dysuria and increase 
of mucus, and the occurrence of pus and sometimes of blood-cells in the 
urine. Occasionally the flow of urine is obstructed by the presence of the 
calculus, and the consequent tenesmus causes prolapsus ani. Prolapsus ani 
and dysuria are important symptoms of stone in the bladder. Sometimes the 
bladder becomes greatly distended with urine, and there may be trickling of 
it, with oedema and soreness of the prepuce and adjacent parts. Now and 
then a calculus lodges in the urethra, producing more or less retention of 
urine, with oedema of the prepuce and adjacent parts. The treatment for 
calculus must be entirely surgical, and will be considered hereafter. 

Dysuria occurs from various causes. It not only results from calculus, 
but also from urine concentrated and acid. We have stated above that urine 
containing uric acid and the urates, if they are abundant, is highly irritating, 
and while this acid and its salts increase the frequency of micturition, they 
are likely to render it painful. They sometimes cause colicky pain from 
spasmodic contraction of the muscular fibres in the urinary tract, and even 
transient albuminuria has been noticed. Dysuria from this cause is best 
treated by alkaline and mucilaginous drinks. 

Dysuria not infrequently arises from a morbid state of the external gen- 
itals, and they should always be examined when micturition is painful or 
obstructed to ascertain their condition. In the first two or three years of 
life the prepuce is usually adherent to the glans through epidermal cells, 
which appear to arise from the rete Malpighii, and instead of becoming horny 
remain soft and filled with protoplasm. This adhesion is so common that it 
must be considered normal, especially as it does not give rise to symptoms. 
But occasionally, even in young boys, a pathological state sometimes occurs 
which gives rise to symptoms, among which is dysuria. Phimosis may be 
present, retarding the flow of urine, some of which is retained under the 
foreskin, where, decomposing, it excites balanitis, causes adhesions, and ren- 
ders urination painful. Stretching the foreskin so as to expose the glans, 
break up the adhesions, and remove the balanitis, or circumcision, which has 
the same effect, gives relief to the local disease and the dysuria. 

In young girls the labia minora are often adherent, apparently through a 
catarrhal inflammation. They can, for the most part, be readily separated by 
traction, when minute drops of blood appear upon the exposed surfaces, show- 
ing that a vascular connection has already occurred. Henoch 1 says : " In a 
few cases this adhesion appears to me to be the cause of dysuria, which dis- 

1 Diseases of Children, 1882. 



936 LOCAL DISEASES. 

appeared after the separation of the labia from one another ; in others exam- 
ination showed inflammatory redness of the introitus and meatus, with 
increased secretion of mucus, which renders the excretion of urine pain- 
ful." Separating the adherent parts and covering the surface with aristol 
or a simple ointment to prevent readhesion suffice to effect a cure of the 
dysuria when it depends upon this cause. 

In the first months of foetal life the testes lie in the abdominal cavity in 
front of and a little below the kidneys, behind the peritoneum, and attached 
to the base of the scrotum by a long cord, the gubernaculum testes. Between 
the fifth and sixth months the testes descend to the iliac fossa, with corre- 
sponding shortening of the gubernaculum. At the end of the eighth month 
they have descended into the scrotum, surrounded by a pouch of the perito- 
neum which becomes detached from the peritoneum "just before birth" 
(Gray), forming a closed sac, the tunica vaginalis. It is estimated that in 
one case in five the descent of the testicle is delayed from a few months to a 
year after birth. Astley Cooper states that the descent does not occur in 
some cases until between the thirteenth and seventeenth years. When there 
is this late descent intestine is apt to follow the testicle, causing inguinal 
hernia. In about one case in one thousand, it is estimated, the testicle 
does not descend, but remains in the abdominal cavity, either on account of 
adhesions to the abdominal viscera, the small size of the ring, or some defect 
in the gubernaculum. Occasionally, a retained testicle has the normal struc- 
ture and development, but, as a rule, it is imperfect and small, like the tes- 
ticle of the infant, and it is prone to fatty or fibrous degeneration. If both 
testicles are retained, impotence may result on account of the non-develop- 
ment or degeneration. No treatment is required for the retained testicle, 
unless it become inflamed when lying in the inguinal canal, when it should 
be treated by poultices and other soothing remedies. 

Vulvitis. — Inflammation of the vulva is common in girls under the age of 
five years. Like most other inflammations, it varies in severity in different 
cases, from a mild and transient attack to one attended by tumefaction and 
excoriation or ulceration of the labia, pain, and abundant discharge. Ordi- 
narily, when the physician is consulted, the disease has continued a few days, 
and he finds the vulva moist from a muco-purulent discharge, which dries into 
light-yellow crusts and produces greenish or yellowish stains on the under- 
clothes. The vulva and lower part of the vagina are sensitive and red, and 
the acrid secretions sometimes cause redness of the skin over which they flow. 
Frequently the labia are swollen and tender, the patient may complain of 
soreness from friction in walking, and sometimes dysuria occurs from exten- 
sion of the inflammation into the urethra. In severe cases ulcerations or 
erosions upon the labia result, increasing the distress of the patient. 

Vulvitis is sometimes aphthous. Small rounded elevations appear upon 
the vulva and ulcerate, and the adjacent surface is red and more or less 
swollen. The ulcers are sensitive and painful, but under ordinary circum- 
stances they progressively heal. Rarely, in those who are markedly cachec- 
tic, the ulcers become gangrenous and recovery is tedious and uncertain. 

Etiology. — The most common cause of vulvitis appears to be uncleanli- 
ness, and hence its frequency in the families of the poor and degraded in 
cities. The collection of dirt and sebaceous matter upon the vulva, and the 
irritation to which it gives rise, which prompts the patient to rub or scratch 
the parts, cause inflammation. Struma strongly predisposes to this inflamma- 
tion, so that slight irritating causes develop it in those who possess this 
diathesis. A considerable proportion of those who have vulvitis have or 
have had other manifestations of scrofula and present the strumous aspect, so 
that it seems proper to consider the inflammation of the vulva occurring under 



DISEASES OF THE GENITO-URINARY ORGANS. 937 

such circumstances as possessing a strumous character or as a local manifesta- 
tion of the strumous diathesis. We therefore, with Dr. West, regard struma 
as an important predisposing cause of vulvitis in the child. Ascarides in the 
rectum have long been recognized as a cause, producing this effect by the 
intense itching which prompts the patient to rub the parts and thereby inflame 
them. It is said that ascarides sometimes crawl to the vulva, and produce 
inflammation by their presence upon the sensitive surface. A last and most 
important cause is infection by gonorrhceal pus. Every physician who sees 
cases in the dispensaries or tenement-houses of our large cities meets cases, 
even girls of three or four years, in whom vulvitis has this cause. Sometimes 
the gonorrhoea is communicated criminally ; in other instances it is contracted 
from the infected seat of a privy or from soiled towels or linen. A young 
man whom I attended was under treatment for gonorrhoea, when his two 
nieces of about four and six years were infected by the same disease, probably 
from soiled towels. The anatomical characters do not enable us to discrimi- 
nate between gonorrhceal and non-specific vulvitis, but the differential diagno- 
sis may be made by observing the gonorrhceal microbe in the secretions of the 
one and its absence in those of the other. In both forms of vulvitis the 
muco-purulent secretion and the inflammatory lesions are identical. The 
danger of infecting the conjunctiva and producing purulent ophthalmia from 
inoculation with the secretion of vulvitis is well known. On the other hand, 
it is believed by some that vulvitis is occasionally caused by inoculating the 
vulva with the muco-pus of ophthalmia. 

Treatment. — The parts should be frequently bathed with the following 
lotion, used warm to ensure cleanliness, and the same, also warm, should 
be injected three or four times a day: 

R. Acidi borici, 3jj ; 

Sodii borat., 3j ; 

Glycerin i, %j ; 

Aquae pura, Oj. — Misce. 

Then, after delaying a few minutes, the parts should be dried with borated 
cotton, and the following powder should be dusted on the internal surface of 
the labia : 

R. Pulv. zinci stearat., 

Pulv. acidi borici, da. ^ij ; 

Pulv. amyli, Jj. — Misce. 

If the vulvitis have a gonorrhceal origin, bichloride of mercury (1 : 5000) 
or carbolic acid (1 : 200) should be used once or twice daily as a wash. 

Preputial Dilatation. — The celebrated French podiatrist Saint-Germain, 
surgeon to the Hopital des Enfants, Paris, presented a paper on preputial 
dilatation before the section of Diseases of Children at the Ninth Inter- 
national Medical Congress, held in Washington in 1887. From this paper 
the following is extracted: 

" Since circumcision is sometimes followed by accidents, such as hemor- 
rhage difficult to control, partial gangrene, diphtheria of the wound, 1 have 
almost entirely given it up, and reserve it for those cases in which dilatation 
is impracticable (these cases are in the proportion of 1 in 300). 

" I employ dilatation. This operation, devised by Nelaton and since 
adopted by the majority of surgeons, consists of the introduction into the 
preputial orifice of a dilator of two branches, and not three, as employed by 
Nelaton, and in the gradual and slow dilatation of the orifice. This opera- 
tion, which is completed by separating the adhesions by the aid of a grooved 
director and by daily movement of the prepuce, by which the glans is alter- 



938 LOCAL DISEASES. 

nately uncovered and covered, has given me the most satisfactory and durable 
results." 

During the last ten years preputial dilatation has been largely practised 
in certain institutions in New York as a substitute for circumcision, and 
almost invariably with a good result. The closed blades of the thumb- 
forceps of the surgeon's pocket-case, making a probe which can be forced 
through even a pinhole preputial orifice, are introduced half an inch to one 
inch between the prepuce and glans, and allowed to expand. The separated 
blades in a few minutes stretch the foreskin sufficiently to allow the tip of the 
glans to be seen; the glans itself, then acting as a wedge, will enable the 
operator to bring in view not only the glans, but the corona, from which 
the smegma should be gently removed by oiled cotton, and the adhesions 
resulting from the balanitis broken up. After applying oil the foreskin 
should be returned. With the exception of the use of the forceps, which 
will be unnecessary, this treatment should be employed daily. I have not 
seen a child under the age of six months in which preputial dilatation could 
not be readily and advantageously performed, but in older children, in whom 
the repeated balanitis has caused thickening of the foreskin, circumcision is 
preferable, and it will always be performed as a religious rite by the Jewish 
population. 

The Kidney. 

Abscess of the kidney (pyonephrosis) in children is very rare. It may 
follow an injury, as rupture, or may result from interstitial nephritis or em- 
bolism. The kidney is markedly enlarged ; its capsule and the adipose tissue 
in which it lies are congested and cedematous. Beginning as a superficial 
affection, it extends to the renal parenchyma and involves all the connective 
tissue of the kidney, which culminates in suppuration at various points. The 
diagnosis of traumatic nephritis rests upon the history of the injury, and the 
passage at first of blood and afterward of pus in the urine, to which are 
added great local tenderness, chills with fever, dull or sharp pains through 
the part affected, and finally a tumor perceptible on examination. Pus must 
be evacuated by incision in the loin. The opening should be free, and the 
walls of the abscess should be stitched to the margins of the wound ; a drain- 
age-tube should be inserted. Even if nephrectomy is performed subse- 
quently, nephrotomy renders the former less dangerous. 

Case. — A boy, aged nine years, received a blow over the right kidney from a 
ball. He suffered for several days from the contusion, and his urine contained 
blood in small quantities, A chill occurred on the tenth day, followed by fever and 
pus in the urine. On the fifteenth day a well-defined swelling in the anterior part 
of the loin was detected. A hypodermic syringe with a long needle withdrew pus. 
A vertical incision was made in the loin, and a large quantity of pus was evacuated. 
An exploration showed that the abscess formed in the kidney. The cavity was dis- 
infected and drained, and the patient made a good recovery. 

Perinephric abscess may result from injury, abscess of the kidney, or 
from unknown causes. It consists in the formation of pus in the connective 
tissue around the kidney. The symptoms are pain in the vicinity of the 
kidney, rapid pulse, fever, swelling in the lumbar and iliac regions, which 
have a doughy feeling. As the disease progresses, the tumor enlarges, fre- 
quently filling up the iliac fossa and protruding under Poupart's ligament or 
along the edge of the ilium ; it may also pass upward behind the perito- 
neum, and, penetrating the diaphragm, form connections with the lung, and 
finally discharge through it, or it may find an outlet for its contents into the 
bowels, rectum, bladder, or vagina. The early treatment must aim to subdue 




DISEASES OF THE GENITO-UBINAEY ORGANS. 939 

the inflammation by absolute rest ; laxatives or enemata ; leeching, opium to 
relieve pain, with quinine and nourishing food ; auscultation of the lung 
should be frequently practised, especially in obscure cases, to anticipate any 
tendency of the pus to find its way out in that direction. Constant attention 
must be given to the formation of the characteristic enlargement in the 
lumbar region ; when this appears and the nature of the 
disease becomes manifest, an early operation is de- Fig. 253. 

manded ; for a premature opening, in anticipation of the 
formation of matter, is better than that any delay should 
occur in giving exit to the pus. 

The point of operation should be, as a rule, in the renal 
region, in order to avoid the peritoneum, and where fluctua- 
tion is most distinct, unless the abscess point below, as along 
the ilium or at Poupart's ligament ; if the swelling is de- 
fined, and the abscess shows no sign of pointing, select the 
margin of the quadratus lumborum, or a point midway be- 
tween the last rib and ilium, on a line vertical to the centre of incision for perine- 
the ilium (1, Fig. 253) ; introduce an aspirating needle, and if phritic abscess, 

pus is found, make this the guide to a straight, narrow- 
bladed knife, and open the swelling freely ; if pus is not found, carefully dis- 
sect by transverse incisions through the skin, fasciae, and connective tissue, until 
the abscess is reached, when it should be freely opened ; if no pus is found, the 
wound should be kept open for the purpose of securing its early escape. The 
escape of pus once secured, the cavity should be thoroughly washed out with dis- 
infecting fluids, and maintained in an open condition until the cavity closes by 
granulation. 

Tuberculous kidney appears in its early stages as a pyelitis, with few 
marked symptoms, but as it advances there is pain in the loins, tenderness on 
pressure in the lumbar region, increased area of dulness, and often a tumor 
can be felt ; the urine may not be altered or may be excessive, and contain 
albumin, blood, and debris of renal tissue. The diagnosis must be between 
scrofulous and calculous disease, and the constitutional condition of the 
patient must determine the former affection. The chief indications of scrof- 
ulous kidney are a poor and weakly physique, with existing or threatening 
lung symptoms, suppurative pyelitis, glandular swellings of the neck, with 
an irregular and occasionally high temperature, and with vesical irritation. 
The treatment should at first be palliative. If the disease progress, nephrot- 
omy should be performed with a view to evacuate and drain one or more 
abscesses in the kidney if the disease is limited. If the kidney is generally 
involved, or if, after nephrotomy, the disease extend, nephrectomy may be 
performed. 

Tumors of the kidney are of great variety, but the sarcomatous form is 
most frequent in children. The following features are important in diagnosis : 
1. The large intestine is usually in front of the tumor, to the inner side on 
the right and to the outer side on the left. 2. Tumors do not project or 
protrude backward, like abscesses, but expand in front. 3. They have the 
rounded form and outline of the kidney. 4. They move slightly or not at 
all in respiration. 5. When the tumor enlarges so as to press the abdominal 
wall, the most anterior point at which it comes in contact is commonly about 
the level of the umbilicus or a little higher. There are occasional excep- 
tions to these rules, but rarely to the rounded outline of a renal tumor. 
Little or no reliance can be placed on the absence of changes in the urine, 
but pyuria and hematuria are valuable adjuncts in forming a diagnosis, 
when present. 

Removal of the kidney is the proper method of treatment, and has 



940 LOCAL DISEASES. 

resulted favorably. Abbe 1 reports two cases in children; both recovered 
and remained well for upward of a year. He took the precaution to place 
his patients in the Trendelenberg position, with the body inclined at an angle 
of 30°, and retained them in this position for two days. He prevented shock 
by warmth and enemata of hot black coffee. 

Nephrectomy, excision of the kidney, may be performed in the lumbar 
or abdominal region. 

(a) Lumbar nephrectomy is as follows : 

Make a transverse or slightly oblique incision as in nephrotomy, and somewhat 
nearer the last rib than in lumbar colotomy ; with this should be conjoined a second 
incision running longitudinally downward from the first, and starting from it about 
one inch in front of its posterior extremity. The first incision should be about four 
and a half inches in length, and not nearer the twelfth rib than half an inch, for 
fear of wounding the pleura, which sometimes descends a little below it. The 
second incision may be left until the kidney has been reached and explored, and 
can then be made by cutting from within outward with a probe-ended bistoury 
steadied by the index finger of the left hand. The kidney being reached, separate 
it from its surroundings ; when no perirenal inflammation has existed, the colon, 
peritoneum, and fatty tissue will easily be detached from their connection with the 
kidney by the index finger of one hand worked close against the capsule of the organ. 
A double ligature of plaited silk is next passed through the pedicle between the 
ureter and the vessels by means of an aneurysm-needle fixed in a long handle, 
whilst the kidney is dragged well up into the wound by the operator's left hand, 
one of the fingers of which can at the same time be acting as a guide for the needle ; 
the needle passed and withdrawn, divide the ligature silk, and tie one-half tightly 
around the vessels, and the other half around the ureter, pressing the ligatures 
well inward toward the front of the spine, so as to leave plenty of room between 
them and the hilus for dividing the pedicle. Now draw the kidney quite out of the 
wound, aiding the manoeuvre by dragging the lower ribs forcibly upward with 
the fingers of the left hand dipped into the wound. Another ligature should be 
thrown around the whole of the pedicle, and securely and tightly tied before cutting 
the kidney free, which is now safely done by snipping through the ureter and 
vessels with a pair of blunt-ended scissors. All bleeding vessels should be securely 
tied, and all of the ligatures cut off short, and the pedicle dropped into the wound. 
A drainage-tube should be inserted, the edges brought together with waxed-silk 
or fishing-gut sutures, and antiseptic external dressings applied. The patient 
should be kept in the recumbent position until healing is complete, and the drain- 
age should be kept up for four or five days. 

(5) Abdominal nephrectomy is preferred in cases of large tumors. 

Operate as follows : Make an incision along the outer border of the rectus ab- 
dominis muscle on the side of the kidney to be removed ; the middle point will proba- 
bly correspond with the umbilicus, but this will depend upon the size and outline 
of the tumor. All bleeding being arrested, open the peritoneal cavity, and first 
ascertain the presence and condition of the opposite kidney. Keep the intestines 
aside from the kidney to be removed by a flat aseptic sponge introduced into the 
abdomen. Now, open the outer layer of the mesocolon sufficiently to allow of the 
introduction of two or three fingers behind the peritoneum and into the fat in front 
of the kidney, and the fingers should then gently tease their way toward the renal 
vessels, around which ligatures should be secured. 

The Urinary Bladder. 

In infancy the bladder is pyriform in shape, and it is situated higher 
than in the adult, being rather in the abdomen than in the pelvis. The 
base of the organ does not sink in the pelvis, but is more nearly on a plane 
with the orifice of the neck. 

Foreign bodies are occasionally introduced into the bladder through the 
1 Annals of Surgery, vol. xix. 






DISEASES OF THE GENITO- URINARY ORGANS. 941 

urethra, and may be of every variety of structure and consistency. What- 
ever may be their nature, they tend to form nuclei for the deposit of the 
urinary salts, and either by themselves or by the concretions formed become 
sources of severe irritation of the bladder. The symptoms are those of 
vesical irritation from stone — namely, pain, obstruction to the free passage 
of urine, and evidences of cystitis. The presence of a foreign body may be 
acknowledged by the patient or discovered by exploration of the bladder. 
The foreign body must be removed, and in such manner as to create the least 
possible injury to parts. The most serviceable instrument for general use, 
as in the removal of a portion of catheter, pin, bead, slate-pencil, small stone, 
is the lithotrite (Fig. 254). It may be laid down as a rule that rigid and 

Fig. 254. 




G. 7' I EM ANN. CO. N. Y 

Lithotrite. 

elongated foreign bodies tend to assume a transverse position, but if their 
dimensions exceed six or eight centimetres,, they cannot rest in this position, 
but must lie obliquely. 

In searching for a body in an empty bladder it may be impossible to move the 
instrument save in a lateral direction, and if this cannot be done the operator may 
be sure that the bladder has not been entered. When, however, the bladder is dis- 
tended, as by an injection, these conditions immediately change ; the foreign body 
becomes movable, and its position is no longer regulated by physiological but by 
physical laws ; distention of the bladder by injection, therefore, so far from favor- 
ing the search for and extraction of the body, really hinders these manoeuvres. 

The lithotrite is made of two halves, one sliding within the other, and is like an 
ordinary catheter when closed ; it is introduced into the bladder by the urethra ; 
then, by means of a screw or rack and pinion worked on the outer extremity, the 
movable part is made to slide back within the bladder, now forming two jaws, by 
which the body is seized ; by turning the screw or handle the blade is propelled 
onward, and the substance is firmly held and compressed, if possible, so as to 
admit of being removed readily by the urethra. 

It is desirable to seize the body with the jaws of the lithotrite in such 
manner as will present its long axis to the long axis of the urethra. The 
exact position of the foreign body having been determined, place the beak of 
the instrument in immediate contact with it; now open the jaws by turning 
the screw, and when sufficiently separated give the beak a slight lateral 
movement, and turn the screw so as to close the jaws ; if the object is seized, 
the position of the screw will indicate its size. If, on attempting its with- 
drawal, the body cannot be engaged in the urethra, the instrument must be 
loosened and the body seized again with a view to change its diameter. If 
all efforts at extraction fail, the bladder must be opened by median lithotomy 
and the body removed. 

Urinary calculi occur as frequently in children as in adults. The cen- 
tral body is either a crystalloid deposited from solution in the presence of 
colloids or a solid body introduced from without, as a pin. These stones 
vary in composition according to the constituents of the urine in each case. 
The symptoms are pain at the neck of the bladder, along the urethra, and 
under the glans penis ; increased frequency of desire to void urine, with 
spasmodic pain at the close of the act ; blood in the urine at the close of 
urination or after severe exercise ; sudden arrest of the stream of urine while 
in full flow, with strong spasmodic contractions at the neck of the bladder 



942 LOCAL DISEASES. 

attended by severe pain. But the diagnosis must finally rest upon the detec- 
tion of the stone by the sound. 

The first exploration should be made with soft bulbous bougies to esti- 
mate the calibre of the urethra and its sensitiveness ; the second examination 
should be made with a searcher of abrupt curve and short beak (Fig. 254). 
When the sound enters the bladder it must be moved to and fro, to the right 
and left, and then reversed ; large stones usually lie close to the vesical neck 
and are readily felt, but medium and small-sized calculi are more apt to be 
found in the posterior part of the bas-fond on either side of the median line ; 
the contact of the instrument with a calculus will determine by the note 
whether it is hard, soft, or encysted. 

Removal of stone from the bladder must be effected by litholapaxy, by 
which the stone is crushed in the bladder and removed through the natural 
passages without cutting ; or by lithotomy, by which the stone is removed 
through an artificial opening made into the urethra or bladder. The opera- 
tion of crushing the stone to facilitate removal is now generally regarded as 
the best procedure when the calculus does not exceed 60 grains or the size 
of a Spanish nut. Keegan reports a case of the removal of a stone, by crush- 
ing, weighing 703 grains, from a boy twelve years old. 

Gouley truly remarks : " There is no exclusively best method of dealing with 
these foreign bodies, and there is no particular method applicable to all cases even 
of a kind, for experience teaches that one patient will bear immediate surgical ope- 
ration, be it lithotomy or lithotripsy, while another of the same age and apparently 
in the same state will be killed by precisely the same treatment ; the judicious sur- 
geon, therefore, will select from among the many known operative procedures the 
one which is indicated after due consideration and study of all the peculiarities of 
the individual case." 

Litholapaxy and lithotomy are never emergency operations, and as the 
procedures require special instruments and considerable dexterity on the 
part of the operator, it will be advisable for the general practitioner to obtain 
the assistance of a competent surgeon. For the full description of these 
operations works on operative surgery should be consulted. 

Stone in the bladder of female children occasionally occurs. It is 
attended by symptoms of local irritation, cystitis, sudden arrest of urine. 
If the diagnosis is not correctly made out, the stone may cause ulceration of 
the bladder and escape into the anterior part of the vagina. 

Case. — A girl aged six years had suffered eighteen months from all of the cha- 
racteristic symptoms of calculus of the bladder. No exploration of the bladder 
had been made, as the presence of a stone had not been suspected by the medical 
attendant, though the suffering of the patient was extreme. At length the stone 
made its appearance just below the opening of the urethra, and surgical advice 
was sought. A slight enlargement of the opening already existing was sufficient 
to permit the removal of a calculus weighing 110 grains. 

Exploration of the bladder with a probe or sound should at once be made 
in all cases of female children having symptoms of irritation of the bladder 
and sudden arrest of the flow of urine. The examination is readily made 
while the patient is under an anaesthetic, and the presence of a stone can be 
positively determined. The treatment should be prompt removal of the stone 
by the method of crushing. 

The Urethra. 

Simple incised wounds of the urethra are dangerous in proportion to their, 
depth, as regards their direction, and the tissues involved. The indications 



DISEASES OF THE GEXITO-UBINABY ORGANS. 943 

are to prevent extravasation of urine by enlargement of the wound if neces- 
sary or the introduction of a catheter. 

Contused and lacerated wounds of the urethra occur in children as the 
result of falls astride of hard bodies, and are more frequently located in that 
portion related to the deep perineal fascia ; and it is in this part that there is 
the greatest risk to life, owing to the tendency to urinary infiltration and the 
liabilty to intrapelvic suppuration and peritonitis. The rupture is usually 
due to the forcible pressure of the urethra against the triangular ligament. 
The tube may be torn partially or completely across. The symptoms may 
be very slight, but generally there are contusions, inability to pass water, 
and bleeding from the urethra. At first an effort should be made to pass a 
flexible catheter, but the utmost gentleness must be used in order not to 
engage the point in the rent ; if the rent is longitudinal, the catheter may 
pass without much difficulty ; if it is transverse and involves only the lower 
portion, the extremity of the catheter may be passed along the roof; in some 
cases the stilette may be carried in the flexible bougie, and when the obstruc- 
tion is met with by withdrawing the stilette an inch the end of the catheter 
is suddenly raised and passes the obstruction. The catheter should rarely 
be retained, owing to the liability to extravasation by its side. If there is 
hemorrhage, ice must be applied. If the catheter cannot be passed or there 
is a distinct hard tumor at the seat of injury, perineal section must be per- 
formed to give free escape to the urine. Pass a sound down to the rupture 
and make the incision upon its extremity. Delay in the performance of 
this operation causes imminent risk, and probably an aggravation of the local 
mischief. These lesions always render the patient liable to subsequent stric- 
tures, often of an intractable kind, and hence the importance of restoring 
and maintaining the full capacity of the canal in the subsequent treatment. 

Foreign bodies introduced into the urethra from without include every 
variety of materials, as pins, pencils, stones, beads. They tend to advance 
into the bladder, but, if arrested, they cause retention and finally ulceration. 
Immediate removal is necessary. The most useful instrument is forceps with 
a long handle which separates only at the blades (Fig. 255) ; for bodies in the 

Fig. 255. 




Long urethral forceps. 

anterior part of the urethra, slender forceps, with suitable blades are neces- 
sary (Fig. 256) ; pressure must be made behind the body, if possible, to pre- 
vent its being forced backward by the forceps. If the body be long and soft, 
as leather, rubber, or a piece of wood, 

it may be transfixed with a stout needle _^^_ -^ IG ' 256 ' 
through the floor of the urethra and 
the canal pushed back over it, like a 

glove over a finger, as far as possible, Short urethral forceps, 

when it may be transfixed again, and 
so urged forward until it can be seized at the meatus. If the body cannot 
be dislodged, it must be removed by a longitudinal incision. 

Calculus or an angular fragment of a crushed stone may lodge in the 
urethra in its passage from the bladder. The points where it is most liable 
to lodge are — (1) the membranous portion at the triangular ligament ; (2) in 



944 



LOCAL DISEASES. 



Fig. 257. 



the middle of the penile portion ; (3) at the meatus. If the calculus is pos- 
terior to the triangular ligament, push it back into the bladder with a large 
catheter. If it is immovable without great force, which must be avoided, it 
may be forced back by injections through the catheter of warm water, olive 
oil, or flaxseed tea. If the body is anterior to the ligament, it should be 
withdrawn through the meatus by means of the forceps mentioned. 

Imperforate urethra may consist of a closed meatus, which must be 
opened by puncture or incision. Or the closure may be due to a diaphragm 
lower down in the urethra, which must be perforated by a trocar. If the 
tube is deficient for a considerable extent, a new urethra must be con- 
structed. 

The Penis. 

Phimosis is such a contraction of the prepuce that the glans cannot be 
uncovered ; in the normal condition of the infant the prepuce is adherent to 
the glans, but later these adhesions are broken down and 
the prepuce becomes free. If, however, there is inflamma- 
tion excited by irritants, as accumulations of filth under the 
prepuce, these adhesions may become firm ; or the orifice 
may become inflamed and so dense that it will not yield, 
even to allow the free passage of urine (Fig. 257). The 
affection may be a source of great discomfort in children, 
resulting in spasms of the muscles of different parts of the 
body, and in adults of collections of filth and foul matters. 
In performing this operation it is important to seize the 
orifice of the prepuce for the purpose of making suitable 
traction on the mucous membrane, which is but slightly 
elastic compared with the skin. 

. , ., , First, insert a well-oiled probe under the prepuce, and 

In phimosis sweep the surface of the glans to break up adhesions ; seize the 

prepuce, including the mucous membrane, with sharp-toothed 

forceps, and draw it forward (Fig. 258) ; grasp the prepuce firmly just in front of 

the glans with forceps, and with the bistoury cut away the portion anterior to the 

Fig. 258. 





Circumcision in the adult. 



clamp ; the prepuce readily retracts : now with blunt scissors slit up the mucous 
membrane on the dorsum, trim its edges, and unite the mucous and skin flaps 
by a number of fine sutures ; if the prepuce is not free, all tightness must be 






DISEASES OF THE GESITO-UEIXARY ORGANS. 



945 



relieved by an incision on the dorsum, or, in infants, by tearing the tissues ; the 
cut mucous membrane must be attached to the skin by numerous fine sutures, 
beginning at the raphe ; rest and water dressings only are required in the after- 
treatment. In slight cases it may be sufficient to slit up the prepuce on the dorsum 
and attach the edges as before. If there is a contracted prepuce after the excision, 
slit up the skin three to six lines on the dorsum of the penis (Fig. 259), trim the 
corners round. 5, 4, 6 (Fig. 260), incise the mucous membrane 2, 1, 3 (Fig. 260), 
adjust the point 1 to 4, 2 to 5, and 3 to 6, with sutures, and the rest of the circum- 
ference by a sufficient number to hold them in position. 

Paraphimosis occurs when the prepuce is withdrawn behind the glans 
and cannot be brought forward ; the prepuce forms a constricting band 
around the corona, which is followed by swelling of the glans and oedema of 



Fig. 259. 



Fig. 260. 





Preparation of flaps. 

the prepuce. The treatment is prompt reduction. If the swelling is slight 
and without strangulation, reduction may be effected by the methods given 
below, or by strips of rubber plaster applied longitudinally from the middle 

Fig. 261. 




Reduction of paraphimosis. 

of the penis on one side over the apex of the glans to the middle of the penis 
opposite, the meatus being left uncovered until the organ is covered. If 
there is dangerous strangulation, shown by the dark color of the glans 

60 



946 



LOCAL DISEASES. 



and great oedema of the prepuce, reduction is more difficult, but may be 
aided by employing cold and puncture of cedematous parts. Reduction is 
effected as follows : 

Give an anaesthetic ; seize the penis behind the strictured prepuce, between the 
index and middle fingers of both hands, placed on either side (Fig. 261), make 
pressure with the thumbs on both sides of the glans, in such direction as to com- 
press the glans laterally rather than from before backward, and at the same time 
pull the strictured portion of the prepuce forward ; the manipulation is designed to 
reduce the glans by compression and pull the stricture over the glans, and not to 
push the glans through the stricture. 

Or the penis may be encircled with one hand (Fig. 262) while compression is 
made with the thumb and finger as before. Or place the index and middle finger 

Fig. 262. 




Reduction of paraphimosis. 




of the rio-ht hand longitudinally along the lower surface of the penis, and the pulp 
of the thumb on the dorsum of the glans and the oedematous ridge in front of the 

point of stricture ; by firm pres- 
Fig. 263. sure, crowding down the swollen 

mucous membrane of the prepuce, 

endeavor to insinuate the end of 

t the thumb-nail under the stric- 

'C ture ; succeeding in this, grasp 

||k the penis and the two fingers of 

the right hand beneath, in a cir- 
cular manner, with the left hand, 
and draw the strictured point up 
over the thumb-nail, and by sim- 
ultaneous traction of both hands 
replace the prepuce. If a pro- 
longed and careful attempt at re- 
duction fails, the strictured point 
must be divided as follows : Intro- 
Mode of dividing prepuce in paraphimosis. duce a bistoury knife flat-wise 

along the sheath of the penis, 
subcutaneously, under the stricture, and cut outward until all tension is removed 
(Fig. 263) ; or a simple incision may be made down to the sheath of the penis. 




DISEASES OF THE G EXIT 0- URINARY ORGANS. 947 

The after-treatment consists of cleanliness and syringing the preputial cavity with 
carbolized water. 

The Scrotum. 

Varicocele is due to a varicose state of the veins of the spermatic cord, 
resulting in an enlargement of its tissues, forming a pendulous mass, which 
becomes a source of inconvenience. The early treatment is support by 
means of a suspensory bag. If the scrotum becomes very large and trouble- 
some, the spermatic veins must be ligated, with careful attention to all of 
the antiseptic details. 

Hydrocele is an accumulation of fluid in the sac of the tunica vaginalis, 
and is caused by any condition which stimulates that membrane to over- 
secretion. It commences at the lower part of the scrotum and gradually 
extends upward, and when well marked the tumor is tense, transparent, and 
fluctuating, has a smooth and uniform surface ; the testicle is not defined, but 
the spermatic cord can be traced to the swelling ; if the hydrocele is old, the 
walls may be so thick that the transparency is lost. The methods of treat- 
ment most frequently adopted are as follows: 1. Tapping for temporary 
relief: grasp the tumor in the left hand (Fig. 264), the anterior surface 

Fig. 264. 







Tapping a hydrocele. 

being uncovered ; avoiding veins, puncture directly, withdraw the trocar, and 
pass the canula in the cavity, inclined slightly upward and backward ; care 
must be taken not to penetrate so deeply as to wound the testicle. 2. Injec- 
tions often cure : the best are tincture of iodine and carbolic acid. Of iodine 
use 3J to jjiij pure tincture, with platinum canula, and rub the testicle to diffuse 
the fluid ; leave the fluid all in ; the inflammation will be quite severe, but 
curative. 

The Testicles. 

Tubercles of the testis consist of certain cheesy nodules of considerable 
bulk and more or less globular shape, commonly multiple for a time, but 
finally they coalesce to form a single mass remarkable for its peculiar elas- 
ticity, which it retains until a central softening leads to an abscess ; this 
tends to burst and give rise to the well-known fistula, which is distinguished 
by extreme chronicity and occasional discharge of sodden shreds of seminif- 
erous tubuli through it. Suppuration rarely occurs in children. The treat- 
ment should be largely hygienic, as exercise in the open air and nutritious 
food ; quinine, iron, and cod-liver oil are the most useful remedies ; the testis 
must always be supported. Castration is required to prevent general gland- 
ular infection if the disease involves the organ extensively. 

Sarcoma in all its principal varieties finds a favorite seat in the testicle ; 
the tumor almost always contains not only all the chief varieties of sarcoma. 



948 LOCAL DLSEASES. 

but all the histioid formations which are met with in the sarcomata as well ; 
cartilage, mucous and connective tissue, striped and unstriped muscle, enter 
more or less into the composition of the sarcomata of this organ ; these fre- 
quent combinations introduce an element of great variety into the structure 
of the sarcomata of the testicle, and this is rendered more manifold by the 
frequent occurrence of cysts in their interior. The growth is slow, usually 
painless, oval, and smooth. The treatment is removal of the gland. 

The congenital malformations epispadias and hypospadias should not be 
operated upon before the patient has reached adult life. 



SECTION VII. 

DISEASES OF THE SKIN. 



As in all other diseases of infancy and childhood, those pertaining to the 
skin in the first years of life have been so fully investigated clinically and 
microscopically in the last decade that they are much better understood and 

Fig. 265. 




Vertical section through the skin (after Heitzraann). Diagrammatic. 

more successfully treated than formerly. At the commencement of the study 
of these diseases the physician should have a clear idea of the nomenclature 

949 • 



950 



LOCAL DISEASES. 



of the cutaneous eruptions. I will therefore briefly present it in detail in 

the clear and concise manner employed by Crocker : 

Maculae " are discolorations level with the skin, of various sizes, shapes, 

and tints." 

Papulae " are small elevations of the skin, not exceeding a split pea in 

size, nor visibly containing fluid." 

Nodulse " are elevations of the skin, from a split pea to a hazelnut in 

size." 

Tumors are " new growths, from a pea and upward in size." 

Vesiculse " are elevations above the surface of the skin, from a pin's head 

to a hempseed in size, with free contents of serous fluid." 

Bullae, or Blebs, " are vesicles which are as large as, or larger than, a pea.'* 
Pustulae " differ from vesicles and blebs only in containing pus." 
Pomphi, ox Wheals, are caused by " a circumscribed oedema of the corium, 

producing a flat elevation of the epidermis at that point." 

Squamae, or Scales, " are dry, laminated exfoliations of the epidermis." 
Crustae, or Crusts, " are irregular, dried masses of exudation or other effete 

products of disease." 

Excoriations " are lesions in which, as a rule, the surface is denuded only 

as far as the stratum mucosum. They heal, therefore, without leaving scars." 
Rhagades " are linear cracks in the skin, whether due to injury or disease." 
Ulcers " are losses of substance of the skin extending into the corium and 

and produced by disease." 

Cicatrices, or Scars, are " new formations replacing losses of substance, 

which extend as far as the corium." 

In a treatise relating to the diseases of infancy and childhood want of 

space prevents a full description of the cutaneous diseases which are liable 

to occur in these periods. We will only describe those which are the most 

frequent and most important. 

Erythema, or Rose Rash, is a term applied to a disease of the skin whose 
clinical character is simple congestion, which disappears on pressure. Its 
color varies from a bright-red hue to a dusky tinge, according as arterial or 
venous hyperemia predominates. As the skin of the child is delicate and has 
an active circulation, and is exposed to many irritating agencies, erythema is 
common at this age. 

1. Erythema produced by external agents ; 

2. Erythema produced by internal causes. 

The causes of the first group are very numerous, among which may be 
mentioned friction or undue pressure upon the skin ; heat, solare or ab igne, 
sufficient to cause erythema; cold of a certain degree produces the same 
result upon the skin, as do numerous irritants of an animal and vegetable 
nature applied to the surface. 

The first group also includes intertrigo, which in its milder forms is an 
erythema, but if severe may present the clinical characters of eczema. It 
often occurs in infants in folds of the skin around the neck and on parts 
covered by the diaper which are irritated by the excretions. 

In the second group certain internal causes, among which are the eruptive 
fevers, particularly scarlet fever, measles, rotheln, and beriberi, produce a 
cutaneous hypersemia which has the anatomical characters of erythema. 
In many children, as well as adults, having an idiosyncracy, erythema is 
caused by drugs, as quinine administered for disease. Under the term 
idiopathic roseola Crocker describes a form of erythema which all will recog- 
nize who are familiar with diseases of children. It "occurs mainly among 
infants and young children. Its onset is generally attended with constitu- 



DISEASES OF THE SKIN. 951 

tional symptoms — a transitory elevation of temperature, sometimes amount- 
ing to three or four degrees, restlessness, quickened pulse, furred tongue, and 
perhaps some redness of the palate and fauces, but there are no catarrhal 
symptoms. After a short but variable period the eruption appears : it may 
be general or partial, affecting the whole body or only a limb, the face, or 
neck ; the form and shape of the eruption vary much, at one time in patches 
of the size of the end of the finger, at another faintly papular, or it may be 
in rings or gyrate figures. It may come at one place and go at another, and 
so last several days." 

Symptomatic erythema occurs suddenly in a variety of febrile attacks, 
the rash having sharply-defined borders, with areas of skin not hypersemic, 
and even white. In erythema presenting a scarlatiniform appearance, but 
without any relation to scarlet fever, the rash usually disappears in two to 
six days, and sometimes with a furfuraceous desquamation. The occurrence 
of this rash shows that there has been some constitutional disturbance, having 
its seat often in the digestive system. When the erythema occurs after the 
use of certain drugs, as quinine and copaiba, the irritation of the alimentary 
canal probably has a reflex action on the vasomotor centres. 

Diagnosis. — Erythema is liable to be mistaken for certain diseases that 
are more severe and protracted and that more urgently demand treatment. 
Scarlet fever is the most noteworthy of these, but this dangerous disease has 
the following characters, which in ordinary cases serve for correct diagnosis : 
Redness and swelling of the fauces, strawberry tongue, vomiting — an initial 
symptom in about nine-tenths of the cases of scarlet fever. To these may be 
added, as indicative of scarlet fever, efflorescence, general instead of limited to 
certain areas with sharply-defined borders, prolonged desquamation, following 
a longer duration of symptoms than in erythema. 

Measles is distinguished from erythema by the presence of coryza, the 
commencement of the rash upon the forehead after three or four days, nasal 
and faucial catarrh, and its gradual extension over the entire body, and the 
constant occurrence of fever from the beginning of the catarrh until the dis- 
appearance of the eruption. In certain cases it will be necessary to observe 
the efflorescence and course of the disease two or three days before making a 
positive diagnosis. 

Eotheln is in some instances with difficulty diagnosticated from erythema, 
but it is accompanied by the enlargement of certain glands about the neck, 
which is lacking in erythema. Eotheln also occurs as an epidemic and feebly 
contagious disease, characters which are lacking in erythema. 

Treatment. — This is simple, consisting of regulating the digestive system 
and the application of a simple dusting powder, as equal parts of subnitrate 
of bismuth, stearate of zinc, and powdered starch, or oxide of zinc 1 part and 
powdered rice or corn starch 3 parts. 

Erythema multiforme is preceded and attended by malaise and slight 
pains in the head, back, and limbs, and sometimes gastric derangement and 
enlarged spleen. In some cases these symptoms are absent. If they be 
present, after their continuance a few hours or days the eruption appears on 
the backs of the hands and feet, upon the face and limbs, and it is abundant 
around the most painful articulations. It is rare upon the body. The tem- 
perature, rising from 100° to 104° in the beginning of the sickness, may fall 
to normal when the eruption appears, or it may not fall until the eruption 
disappears. The extent of the eruption is variable, but, in whatever other 
places it occurs, it is seldom absent from the back of the hands. It begins 
in groups of deep-red papules, from the size of pin's head to a small split 
pea (e. papulatum). Some of the papules, enlarging, may unite, forming 
nodules or tubercles (e. tuberculatum or tuberosum), or by depression of the 



952 LOCAL DISEASES. 

centre a ring forms (e. circinatum or e. annulare). By absorption in the 
centre colored zones of purple or pink ma}- be produced (e. ms or e. 
gyratum). 

The above forms of erythema, as is seen, have been designated by their 
appearance, and some other forms of this disease might be mentioned which 
have also received their appellation from their shape. 

The usual duration of exudative erythema appears to be from two to 
four weeks. 

Pathology. — Cocci have been found in the blood and eruptions of 
patients with exudative erythema. Manssurow found bacilli and spores in 
four cases of erythema multiforme. Many European observers regard this 
disease as specific on account of the fever, its definite course, and its occa- 
sional endemic character. The fact that the effused fluid makes its way 
between the rete-cells and forms vesicles or bullae in which leucocytes occurs 
shows its inflammatory nature. 

Since the various forms of exudative erythema, as of simple erythema, 
tend to recovery in from two to four weeks, those in good general health do 
not require internal remedies. Nevertheless, conditions of the system arise 
in some cases which are benefited by certain kinds of internal medication, as 
iodide of potassium, iron, quinine, salicylate of sodium. 

The following lotion relieves the itching when the skin is not broken : 



R. Acidi carbolici, 


33; 


Zinc camphor, 


Sij 


Aquae purse, 


Qj- 


To be applied as a wash. 





-Misce. 

Urticaria. — This eruption appears without premonition, or with a sting- 
ing and burning sensation resembling that caused by the nettle (JJrtica 
wrens), from which its name is derived. The eruptions are flatly convex, 
firm on pressure, of the average size of the finger-nail, but some of them 
larger from the coalescence of two or more. At first they are red, but in 
developing they become white in the centre. Sometimes the wheal, espe- 
cially if small, remains red. The burning and itching of the eruption may 
be slight, but commonly are so great that the patient scratches vigorously, 
which causes an increase in the wheals and in the extent and intensity of the 
burning and itching. 

The eruption of urticaria continues a few hours or even a day or more, and 
disappears without desquamation. It does not occur symmetrically. Only 
a few wheals may appear, or they may be numerous, covering the entire 
body as well as the mucous membrane of the mouth, tongue, fauces, and 
probably the surface of the air-passages and stomach. The occasional occur- 
rence of spasmodic asthma during an attack of urticaria suggests the presence 
of wheals along the air-passages, and their occurrence in the stomach is ren- 
dered probable by the nausea and vomiting. 

Varieties. — In urticaria papulosa the wheals are small, not more than 
one inch in diameter ; in urticaria tuberosa or urticaria gigans they are of 
longer duration than usual, and some of them as large as a walnut or hen's 
egg ; in urticaria cedematosa the affected tissue is lax and cedeniatous. If 
it occur on the face and extend to the eyelids, the latter may be quite closed. 
If the tongue be the seat of the wheal, the swelling may seem to threaten 
suffocation, but it usually begins to abate in a few hours without the neces- 
sity of an incision. In exceptional instances the subjective symptoms occur, 
but the wheals do not appear, unless, as sometimes happens, they are brought 
out by rubbing or scratching. This form of urticaria is designated subcu- 
tanca. and its usual location is on the lower extremities. 



DISEASES OF THE SKIN. 953 

Hemorrhage may take place into the wheals, producing urticaria hemor- 
rhagica or purpura urticans. An over-abundance of the serum which elevates 
the skin into a wheal may force its way through the rete, and, raising the 
upper layers, produce a bulla (urticaria bullosa). 

Other varieties of urticaria are described by writers, as urticaria jactitia, 
designated also ;i dermagraphia " and " autographism," when letters can be 
brought out in two or three minutes by inscribing with the finger-nail or a 
pointed instrument upon the skin. The term urticaria acuta is employed to 
designate the disease when attended by acute symptoms, as nausea, vomiting, 
pain in the epigastrium or head, and a copious eruption soon appears. Urti- 
caria chronica is applied when successive crops of wheals appear at longer or 
shorter intervals. 

Urticaria papulosa is the form of this malady which is most common in 
children. Bateman designates it lichen urticatus. Instead of mere serum, 
an inflammatory exudation occurs, and therefore after the serum disappears 
a papule remains. Usually when the physician is summoned pale red pa- 
pules of the size of hempseed, with incrusted tops, are observed, the itching 
of which resembles that of scabies. Urticaria papulosa occurs especially in 
the infant about the loins and buttocks, on parts which it is enabled to reach 
and scratch with its finger-nails. The wheals have often disappeared when 
the physician is summoned. If present, they are likely to have a pink color, 
and are of the usual size or small, and may be in some places linear from 
the scratching. 

Etiology. — Urticaria papulosa is likely to be protracted. Hutchinson's 
opinion that it is produced by the bites of fleas and bugs is believed to be 
applicable to only certain cases. A more probable explanation of its etiology 
is that which refers the cause to derangement of the digestive system. 

Urticaria is more common, especially the papular form, in infancy and 
childhood than in adult life. It is also more common in summer than in 
winter. Its causes, as we have seen, are numerous, and may be grouped as 
follows : 

1st. Local irritants which act by immediate contact, as the nettle, insect- 
bites or stings, as of fleas, mosquitoes, the wasp, or bee ; scratching the sur- 
face, as in pruritus or scabies ; irritating plasters or poultices ; sudden changes 
of temperature. 

2d. Indirect irritation. Numerous irritants, acting through the digestive 
system, cause urticaria. Several kinds of food have this effect, as certain 
kinds of meat ; shellfish, as crabs and lobsters ; and in certain persons fruits, 
as strawberries, fungi, and mushrooms. Certain kinds of medicines admin- 
istered to children also cause urticaria, as quinine, turpentine, and valerian. 
Chronic intestinal catarrh, occasionally associated with worms, is also a 
recognized cause, as is also indigestion. The tapping and removal of an 
hydatid cyst and of a pleuritic exudate, asthma, neuralgia, and strong and 
sudden emotions, have been mentioned among the causes. 

Pathology. — The symptoms and history of urticaria indicate that it is 
due to disorder of the vasomotor nerves, direct or reflex, central or peripheral. 
Probably a spasmodic contraction first occurs, followed by dilatation of the 
vessels. The consequent retarded circulation causes exudation of serum and 
oedema, which raises the epidermis into the wheal. The wheal is at first 
pink, but the blood is then pressed out of the centre, which becomes white, 
while the peripheral part is hyperaemic. 

An excision of the wheal made by Vidal showed that the superficial and 
deep-seated vessels were engorged with blood, and the vessels and lymphatics 
were surrounded by leucocytes, which abounded through the whole section 



954 LOCAL DISEASES. 

of the cutis and were in masses in places. Pieces were excised from the 
wheal in which the epidermis had been raised so as to produce a vesicle. 

Diagnosis. — The eruption of urticaria occurs suddenly after the ope- 
ration of the cause, and is white or pink, or of both colors, the white, as 
before stated, being the central part. This wheal, from the characters given, 
is readily diagnosticated from any other eruption. Erythema papulatum, 
which resembles urticaria, is more symmetrical, seldom itches severely, and 
often enlarges by extension of its border, in which respects it differs from 
this disease. 

Prognosis. — Urticaria usually subsides in a few days or hours, but it 
may, if untreated, become chronic. It may disappear in winter and reappear 
in the hot months. Still, in most instances the disease can be cured with 
proper remedies, and will not reappear if suitable preventive measures be 
employed. 

Treatment. — If the urticaria be apparently due to irritating and poorly- 
digested food, an alkaline laxative, as ten to twenty grains of magnesium 
carbonate or Carlsbad salt, repeated if necessary, and aided perhaps by an 
enema, will be found useful. With an open state of the bowels and removal 
of the irritating substance the wheals and pruritus will sometimes disappear 
at once. But if they do not, care should be taken in the selection of the 
food, and it should be given at proper intervals and in proper quantity. In 
such cases bismuth and pepsin taken at each feeding will often be useful. 

In cases of obstinate urticaria the whole system should be carefully 
examined, and if any aberration occurs it should be corrected, but in most 
cases of obscure origin the digestive function is in fault, and by using the 
following prescription it usually improves : 

R. Bismuth, subnitrat., ^ij ; 

Liq. pepsin, gj ; 

Aquae destillat., §iv. — Misce. 

Dose : One teaspoonful after the feeding for a child of one or two years. 

In infantile urticaria associated with chronic intestinal catarrh the above 
prescription is especially beneficial. A careful selection of the diet in these 
infants is especially required. Starch in the food should be predigested by 
the action of diastase ; a fair amount of the predigested meat preparations in 
the shops should be allowed. I have seen benefit from Fairchild's panopep- 
tone or the liquid peptonoids of the Arlington Chemical Works, although I 
seldom recommend the commercial foods. The following remedies in pro- 
tracted and obstinate urticaria have advocates : bromide of potassium, qui- 
nine, galvanism along the spine, ichthyol, strophanthus, sodium salicylate, 
iodide of potassium. 

Scratching the irritated surface with the finger-nails always has an inju- 
rious effect, and the itching should be, so far as possible, prevented by other 
means. Dusting with the following powders will be found useful : 

R • Bismuth, subnitrat., ^ij ; 

Zinci stearat., %] ; 

Pulv. amyli, ^ss ; 

Pulv. camphorse, 3J. — Misce. 
To be dusted over surface. 

R. Lycopodii, § ss ; 

Pulv. bismuth, subnit., 3iss. — Misce. 

Prurigo. — This disease is characterized by papules, slightly raised, dis- 
crete, inflammatory, of a pale-red or white color, and accompanied with a 



DISEASES OF THE SKIN. 955 

severe itching. Two varieties have been described, according to the severity 
of the symptoms — the mitis and ferox. 

Symptoms. — The papules are at first of the color of the skin, and may 
be felt before they are seen. By scratching they become more red, and 
blood-crusts may form at their apices. They are most abundant and highly 
developed upon the extensor surfaces of the limbs, but they occur upon the 
thorax, back and front, the sacral region, buttocks, and abdomen, and other 
places besides those mentioned. The eruption occurs rarely and scantily 
upon the face, and the palms, soles, neck, and scalp are nearly always free. 
The hair is dry, dusty-looking, and dull. 

The itching is severe, and rubbing of the irritated part causes thickening 
of the skin. When the disease is so intense as to be properly designated 
prurigo, the papules and scales are more numerous and of greater size, and 
other eruptions may appear, obscuring somewhat the diagnosis, as eczema, 
urticaria, ecthyma, and glandular enlargements in the lymphatic system. 

Etiology. — Bad hygiene, and especially the lack of proper food, are 
important causes. It usually begins early in life, even in the first year. It 
is not until between the second and fifth year that the disease is fully devel- 
oped, the papules becoming more numerous than at first. If it be not 
actively and properly treated from the beginning, it is likely to become 
chronic and troublesome. Sometimes children well nourished and in good 
general condition are affected. 

Pathology. — This disease is probably primarily an urticaria, although 
Ehlers regards the urticaria as a mere coincidence. A microscopic examina- 
tion of the skin shows an inflammatory exudation of leucocytes and serum 
into the papillary bodies and the derma. The fluid infiltrates the rete, and 
by destroying the cells of the latter elevates the stratum lucidum and forms 
a papule, and in time by absorption a depression or pit occurs. The second- 
ary changes which may take place are like those in other forms of chronic 
dermatitis. 

Diagnosis. — Itching papules, scabbed at the top and dating back to 
infancy, are characteristic of this disease. They have a pale-red color, occur 
chiefly on the extensor aspect of the limbs, and are accompanied by excoria- 
tions. Enlarged glands, secondary eruptions from the pruritus, are charac- 
ters upon which the diagnosis is based. Severe chronic eczema lacks the 
papules and secondary lesions of prurigo. Chronic urticaria, eczema, ec- 
thyma, and the pruritus from pediculi, acari, or from other causes can be 
diagnosticated by a careful examination of the characters present and the 
history of the eruption. 

Prognosis. — The prognosis is better in the young than in the adult. 
Apparent improvement often occurs after treatment, but the appearances of 
convalescence are likely to be deceitful, aggravation of symptoms following 
their decline. 

Treatment. — Measures are required to remove the eruptions, those per- 
taining to the disease as well as those acquired by scratching, and also to 
relieve the troublesome pruritus and improve the health. According to 
Kaposi, " sulphur, tar soap, and naphthol are the most effective agents against 
the itching and the papular eruptions ; " and he especially recommends naph- 
thol, which during the last ten years he has employed in all cases of prurigo. 
When applied too freely this remedy may produce dangerous symptoms by 
absorption, and Kaposi employs only a 1 to 2 per cent, of naphthol in an 
emollient ointment for children under the age of ten years. Every evening 
the ointment is rubbed into the extensor surface of the affected limb, and 
followed by a dusting powder. Every second night the ointment may be 
washed off by the naphthol-sulphur soap. This treatment is continued until 



956 



LOCAL DISEASES. 



the prurigo disappears. If the pruriginous eruption becomes watery and 
covered with scabs, salicylic-acid plaster or Wilkinson's ointment, modified 
by Hebra according to the following formula, should first be used to remove 
the crusts, before the naphthol treatment is commenced : 



R. Sulphuris sublimati, 
01. cadini, 
Saponis viridis, 
Adepis, 

Greta? prseparata, 
At night. 



da. ^lv ; 

da. §j ; 

^iiss. — Misce. 



Eczema. — This term is applied to a catarrhal inflammation of the skin 
which is acute or chronic. It is attended by itching, often severe, and by 
many lesions, including papules, erythema, vesicles, pustules, scales, and 
scabs, while a discharge of serum or pus commonly occurs upon certain parts 
during the progress of the disease. Four forms of eruption can be recog- 
nized during the course of most cases — to wit, the erythematous, vesicular, 
papular, and pustular. This malady is very common, constituting, it is be- 
lieved, as much as one-fourth of the cases of skin disease. Certain forms of 
it are very persistent notwithstanding well-applied treatment. The squamous 
form of eczema is regarded as a subvariety of the erythematous. 

Whatever the form which eczema presents, its beginning is usually acute, 
and it may occur upon any part of the surface, although it is most common 
in certain locations. Vesicles, erythema, papules, and pustules may occur 
simultaneously on different parts of the body or upon the same parts. 

Eczema Vesiculosum. — This is most common where the skin is thin, as 
behind the ears and between the fingers. Pruritus and burning occur, fol- 
lowed by erythema, and soon after by minute transparent vesicles, which 
enlarge, and some of which unite and some rupture, allowing the escape of 
a liquid which stiffens and stains linen. The vesicles rupture either by 
scratching or spontaneously, with some relief to the itching, but the burning 
remains, making the child restless, especially at night. After the rupture of 
the primary vesicles the burning and itching continue from the raw surface 
or from fresh vesicles. It is at this stage, when the vesicles are mostly 
broken, that the physician is usually summoned. If there be but little dis- 
turbance of the inflamed surface, yellow crusts form in the site of the vesi- 
cles, and they are renewed when removed. 

In favorable cases the exudation and redness soon begin to diminish, and 
gradually disappear, or the affected surface may remain red and thickened, 
and become covered with scales, producing — 

Eczema Squamosum. — In this form of eczema the intensity of the inflam- 
mation has diminished. It most frequently appears after eczema erythema- 
tosum. It occurs when the inflammation is of so low a grade that but little 
exudation takes place, but hyperplasia of the rete-cells is present. This form 
of eczema appears in patches of variable size ; coarse or fine scales cover the 
thickened and hypersemic cuticle, which can be readily detached. It occurs 
especially on the neck and limbs, and in a mild form on the face, as thin 
scaly eruptions, with no marked redness or infiltration. This was formerly 
designated pityriasis simplex, and it may apparently be produced by applica- 
tions of soap, and is sometimes accompanied by seborrhoea. Instead of a 
diminution of the exudation, hyperasmia, and other symptoms, these may 
increase, and 

Eczema rubrum is then developed. Eczema rubrum is most frequently 
a sequel of the vesicular or pustular form, although it may result from the 
other varieties. The inflammation is severe, and the skin is denuded of the 



DISEASES OF THE SKIN. 957 

upper layer of the epithelium, has a bright or dusky-red hue, is moist, and 
discharges a clear or glairy fluid, which may form yellowish or brownish 
crusts. This form of eczema is not common in children, but in adults the 
crusts may cover a considerable part of a limb, and when their borders are 
detached they come off easily. The surface underneath is very moist, and 
sometimes blood exudes from it on pressure or slight friction. The infiltra- 
tion and induration in eczema rubrum are greater than in other forms of 
eczema. In the flexures they produce sometimes painful fissures. 

Eczema Pustiilosum or Impetiginodes. — Instead of vesicles, pustules occur, 
due to the irritating action of cocci. They may appear primarily, or the 
vesicles may increase in size and become pustules. It is more common in 
children than in adults, and in the cachectic than in those in good health. 

Eczema papillosum, formerly designated lichen simplex, is the term 
applied to that form of the disease in which papules are produced by inflam- 
mation in the hair-follicles. They are discrete or in groups, or even con- 
fluent, and are seated usually upon the back or extensor aspect of the limbs, 
accuminate, and not larger than a pin's head ; they have a bright or dull 
red color. They may remain papules, or with a lens a minute quantity of 
fluid may be observed at the top of the papules, being the disease formerly 
designated lichen agrius. 

Eczema erythematosnm occurs in its typical form on the face, and is 
attended with heat and swelling. It begins in patches of an erythematous 
appearance, which may extend and coalesce or remain discrete. The color 
is bright or dull red, and the surface has slight scaliness, but no discharge. 
The disease gradually abates, but periods of recrudescence are common until 
the final cure. 

Several other forms of eczema are described by dermatologists, according 
to the anatomical character of the eruption or regions affected, as eczema 
acutum, eczema chronicum, eczema sclerosum, eczema spargosiforme, eczema 
verrucosum, eczema papillomatosum, eczema capitis, eczema genitalium, ecze- 
ma palmare, capitis et faciei, eczema rimosum, etc. 

In children, especially in those under the age of five years, the erythema- 
tous eruption is much more likely to become pustular than in those who are 
older. The tendency of diseases to become pustular is indeed exhibited in 
other forms of inflammation in childhood. Irritants, whether acting externally 
on the skin or internally through the digestive system and in a reflex manner, 
produce an eczema upon some part of the cutaneous surface much more 
readily in children than in adults. Frequently in children the disease occurs 
upon the head, cheeks, and behind the ears. In children having the strumous 
cachexia the inflammation sometimes extends more deeply, causing subcuta- 
neous abscesses, and the adjacent cervical and occipital glands frequently 
undergo hyperplasia. 

Age. — Crocker states that the statistics in a large number of cases 
observed by him show that one-third of all those occurring in children com- 
mence in the first year : in the second and third years the numbers were 
about equal ; and after the third year the number gradually declined until 
the sixth year, and from that age until the thirteenth year the numbers each 
year were about the same. 

According to Unna, the eczema of the face and head in children arises 
from three different causes : First, the seborrheic, commencing perhaps as a 
seborrhea of the scalp. It extends to the ears, forehead, and eyebrows. It may 
extend to the shoulders and upper part of the arms. Secondly, the nervous 
form, which is believed to be due in some cases to gastrointestinal irritation. 
It occurs especially on the lower part of the arm and back of the forearm. 
Third, the tubercular form, which is found chiefly in strumous children 



958 LOCAL DISEASES. 

poorly fed and cared for, and is often connected with strumous conjuncti- 
vitis, rhinitis, or otorrhcea. Crocker regards it as a dermatitis produced by 
" contagious pus." If the conjunctivitis or rhinitis be cured by appropriate 
treatment, this form of eczema disappears by antiseptic applications. 

Etiology. — The causes are very numerous. Irritants which by their 
effect upon the surface produce eczema are chemical, thermal, or mechanical. 
Among the substances that produce eczema by their chemical properties are 
the dilute acids, the soaps containing too much alkali, irritating medicinal 
agents, as turpentine, tartar emetic, croton oil, and other substances which 
are highly irritating when applied to the skin. The thermal causes occur 
from the heat of the sun or artificial heat, and we therefore observe it espe- 
cially in those who by their occupations are exposed to a high temperature, 
as laundry-women, blacksmiths, and cooks. Cold and wet also operate as 
causes. Among the mechanical causes are friction from tight or rough and 
irritating clothing, scratching to relieve itching, and dust occurring in various 
occupations. 

The constitutional causes of eczema must not be overlooked. The general 
health is very likely to be impaired when eczema supervenes. The patient 
is languid, and no longer has the clear and ruddy complexion of health. He 
is lacking in energy, and his nervous system is probably exhausted or in the 
state known in America as neurasthenia. 

Among the external causes of eczema, derangement of the digestive 
system has a prominent place. Diarrhoea or constipation is so frequently a 
concomitant of eczema in children as well as adults that it probably sustains 
a causal relation to this disease. Improper feeding of infants, causing irri- 
tation and perhaps catarrh of the intestinal surface, is also regarded as a 
common cause of eczema. It is known that the rachitic are very liable to 
catarrhal inflammations of the various surfaces, and Crocker and others regard 
rachitis as a cause of eczema. Certain dermatologists also regard struma as 
a cause of pustular eczema. 

Pathology. — Eczema is a catarrhal inflammation of the skin, and 
many leading dermatologists regard it as a peripheral or central tropho- 
neurosis when not caused by local irritation. Unna believes that eczema 
is caused by an undetermined micrococcus, but the opinion expressed by 
Crocker seems to be more plausible, " that, while a limited number of local 
eczemas are parasitic, in most the dermatitis, however caused, only opens the 
door to parasites, whose presence keeps up local irritation, and that their 
destruction is an important step in the restoration of the skin ad integrum." 

The following remarks relating to the anatomy of eczema, together with 
the illustrations, have been kindly furnished by Dr. A. R. Robinson, the dis- 
tinguished professor of dermatology at the New York Polyclinic : 

" Anatomy. — Regarding the term ' eczema ' as equivalent to catarrhal 
dermatitis, a term having a pathological-process significance more than rep- 
resenting a special disease, a clinical entity — for the catarrhal dermatitis or 
so-called eczematous inflammation can be caused by many different factors — 
it follows that, as in other inflammatory processes, the histological changes 
will vary as regards intensity and character in different cases depending upon 
the vulnerability of the tissues affected, the kind of agent causing the changes, 
and the quantity and duration of action of the injurious agent. As the ma- 
jority of the cases of eczema in children are local diseases caused by micro- 
organisms, the nature of the ground and the kind of organism are the deter- 
mining factors in the tissue-changes. 

" In the erythematous form all the vessels of the papillary layer of the 
affected area are changed, as in any mild inflammatory process. The blood- 
vessels are dilated, the walls are changed, there is abnormal transudation and 



DISEASES OF THE SKIN. 959 

emigration into the surrounding tissue, probably in consequence of the leuco- 
toxic and serotoxic action of the toxines from the organisms lying within or 
upon the epidermis, and the epidermis itself is more or less flooded and in- 
vaded by this exudation and emigration. As a consequence, the rete-cells 
are slightly swollen from imbibition of serum, the intercellular spaces are 
dilated, and besides serum contain an occasional emigrant corpuscle. The 
corneous layer also suffers from the transudation. The normal cohesion of 
the cells is interfered with and lessened, and slight desquamation results. 

" TVhen the lesions are papular in character, they are usually situated in a 
hair-follicle or sweat-gland area, especially the former, as the orifices of these 
structures make favorable camping-ground for organisms, and the blood-vessel 
supply is comparatively large in these areas. The vascular changes need not 
be described, as their discussion belongs to general pathology. There are exu- 
dation and emigration, with secondary changes in the corium and epidermis. 
The exudation causes swelling of the papillar and upper part of the corium. 
A portion of the exudation passes into the rete, causing oedema of the rete- 
cells. with disordered molecular constitution or complete destruction. The 
spaces between the cells are enlarged by the serum, the connecting spindles 
are lengthened or torn, and individual cells may become isolated. The normal 
coherence of the corneous cells is disturbed and desquamation follows. 

'• If the process is more intense as regards transudation of serum, the col- 
lection of the liquid within the rete gives rise to a vesicle. In this case a 
clear space forms in the upper part of the rete, usually just below the granu- 
lar layer or stratum lucidum, containing serum and more or less detached 
rete-cells suspended in the serum. The walls are usually ill defined, and 
the rete-cells much deformed as well as changed chemically. The corneous 
layer is more broken up than in the papular form. In Fig. 266 is shown a 

Fig. 266. 




Vertical section of a recent vesicle of parasitic eczema : a, corneous layer ; b, rete ; c, corium ; d, 
vesicle ; e, dilated blood-vessel (after A. R. Robinson). 

section of a recent vesicle, the result of the action of a local agent. The cells 
of the rete do not take any active part in the early changes that lead to the 
formation of the vesicle, and in eczema there are no reasons for assuming a 



960 LOCAL DISEASES. 

primary pathological condition of the rete causing the vascular changes. It 
seems more correct to regard the exudation and emigration and their conse- 
quences as the result of a chemotoxic action — a leucotaxis and serotaxis 
caused by the toxine in all the cases of parasitic eczema. 

" The vesicle at first consists of clear serous fluid and a few isolated or 
broken-down rete-cells, but later pus-corpuscles are usually present and con- 
tinue to increase the longer the vesicle exists. The pustular character de- 
pends generally upon secondary infection by pus-organisms. As long as the 
rete is thus injured by the inflammatory process normal epithelium cannot 
form. The organisms must be destroyed and the circulatory disturbance 
corrected by appropriate treatment. 

" In neurotic eczema (toxic eczema) the vesicles are frequently more or 
less grouped, and, I think, often deeper-seated than when the primary cause 
is a local one. The disorganization of the rete is not so great ; the vesicle is 
formed by serum that makes a vesicle-area by pushing aside and compressing 
the rete-cells more than by causing rupture of the connecting spindles. For 
quite a distance, however, beyond the clear vesicle the rete-cells that are not 
flattened out show an oedeinatous condition from serum imbibition interfer- 
ing with normal epidermis cell-formation and change. The lower rows of 
rete-cells are not so changed as in the parasitic form, neither does the serous 
transudation into the corium and papillary layers appear to be so great. 
Perivascular round-cell collection is more prominent than the transudation. 
The corneous layer is also less affected, and the vesicles as a consequence are 
less liable to rupture. 

" In Fig. 267 is shown a section of a group of vesicles from the palm of 
the hand. The eruption was symmetrical and the lesions grouped. In these 
cases the lesions do not tend to form around a hair-follicle, and may remain 
limited to a small area for a long period. 

" In cases of eczema in which there is a diffuse surface (catarrhal derma- 
titis) the exudation is not so liable to form papules or vesicles, but, apart 
from that, the histological characters do not call for special description. If 
there is a mixed infection from pus-organisms, the serous exudation becomes 
purulent in character — a condition often justifying the use of the term sup- 
purative catarrhal dermatitis or impetiginous eczema. 

" The seborrhoeal form of eczema is always caused by organisms which 
reside in the epidermis and cause a subacute dermatitis, in which it is rare 
to find vesicles or pustules. In this form of disease the corneous layer is 
disturbed, and the cells are thrown off in lamellar form ; the rete shows en- 
larged intercellular spaces, and the prickle-cells undergo various degrees of 
degeneration. In the corium the blood-vessels are dilated ; there is a mod- 
erate amount of serous transudation and a marked perivascular round-cell 
infiltration. 

k ' In chronic eczema rubrum the corium is thickened from exudation and 
round-cell infiltration and plasma-cell formation. The papillge are enlarged 
from the same cause. The boundary between the corium and the rete is 
often difficult or impossible to recognize, on account of the round-cell col- 
lection and inflammatory changes on the one side, and the changes in the 
rete on the other side destroy the characteristic boundary-line. In the rete 
the lower rows of cells are separated from each other and intermingled with 
serum and lymphoid cells. The rete-cells are swollen, oedematous, and ex- 
hibit various degrees and forms of degeneration. The shape is also distorted, 
and may be roundish, oval, or spindle-form, with even or irregular outline. 
Vacuolation-areas are frequently present, and the vesicles may be the only 
part to color with staining dyes. The granular layer is generally imperfectly 
formed, and hence an abnormal corneous layer, many cells of which still show 



DISEASES OF THE SKIN. 



961 



a nucleus. This corneous layer is more or less thinned, the surface irregular, 
and the normal union of the cells disturbed or destroyed. The lymph-spaces 
between the rete-cells are enlarged, as already mentioned ; the rete-cells are 
oedematous, the granular layer is changed, the corneous layer partly de- 
stroyed ; hence in chronic eczema of this form — the clinically chronic, but 

Fig. 267. 







Section of a group of vesicles in a case of neurotic (toxic) eczema of the palms : a, corneous 
layer ; 5, stratum lucidum ; c, rete ; d, corium ; e, dilated blood-vessel ; /, vesicle (after A. R, 
Robinson). 

histologically acute — the above-described changes greatly favor a continuance 
of the disease. The indications in treatment would be astringents for the 
circulatory disturbance and oedema of the rete, and keratoplasty applications 
for the epidermis, together with treatment for the direct cause, which is 
usually a microbe. 
61 



962 



LOCAL DISEASES. 



" The longer an eczema lasts, the deeper are the inflammatory changes, and 
the thicker the skin as a consequence. In long-continued inflammations the 
hair-follicles and sebaceous glands may be destroyed, but that is an unusual 
occurrence. 

" Occasionally as the result of an eczematous condition a hyperplastic 
process takes place, by which the corium, including the papillae, is hyper- 
trophied from new connective-tissue formation, giving the affected area a 
warty appearance, which has been described as eczema verrucosum. In 
Fig. 268 is shown a section of chronic eczema rubrum with the changes just 




Section from a patch of chronic eczema of the leg : a, corneous layer ; b, stratum lucidum stri- 
atim; c, papilla? ; d, interpapillary rete ; e, deep part of corium (after A. R. Robinson). 



described. The round cells and nuclei should have been drawn as deeply- 
stained objects to bring out the drawing. The broken-up corneous layer is 
well shown, as well as the merging of the rete and subepidermal tissues into 
each other. 

" In chronic eczema squamosum the corium and papillae show dilated 
blood-vessels and round-cell collection, with more or less disappearance of 
the ground-substance. The epidermis is not much changed ; there is slight 
enlargement of the intercellular spaces in the rete and also in the corneous 
layer, with consequent cell-desquamation — scale-formation — in macroscopi- 
cal quantity." 

Diagnosis. — This may be difficult or easy. It is comparatively easy if 
the case be one of the four typical forms of eczematous eruption — to wit. the 
vesicular, pustular, papular, and erythematous — or if there be the history of 
a continuous discharge, whether serous or pustular, which stains or stiffens 
linen. Vesicles or pustules not eczematous dry without rupture, or if rup- 
tured dry as soon as the liquid escapes. 

The following mistakes in diagnosis may occur : 

Vesicular eczema and scabies may be mistaken for each other. Both 
have itching and produce vesicles, pustules, crusts, and scales. The history 



DISEASES OF THE SKIN. 963 

of contagion of course indicates scabies. The presence of this disease between 
the fingers, upon the wrists, and the flexures generally is also characteristic 
of scabies, although eczema may occur in these situations. In doubtful 
cases the treatment for scabies will quickly determine the nature of the 
malady, and the use of remedies which destroy the acarus is justified as a 
means of diagnosis. 

Syphilitic pustules on the scalp often resemble the pustules of eczema, 
but they differ from the latter in the occurrence of ulcers and scars, in the 
presence of a peculiarly offensive odor, and in being more circumscribed. 

There is a considerable number of other diseases which might by careless 
examination be mistaken for certain forms of eczema, and vice versa, and 
to make accurate diagnosis in many instances requires a careful examination 
and frequently more than one visit. 

Prognosis. — Eczema is usually a chronic disease if correct treatment be 
not employed, but with correct treatment, perseveringly applied, a gradual 
cure is usually effected. Fortunately, certain causes of eczema which render 
it obstinate in the adult do not exist or are rare in the child, as, for example, 
varicose veins or gout. 

Treatment. — The general condition of the child should be carefully 
investigated, so as to ascertain if there be any injurious influence, dietetic, 
hygienic, or other, which impairs the general health. This if present should 
be removed, or so far as possible modified. The condition of the digestive 
system must especially receive attention. Constipation is common in the 
eczematous, and must be removed as preliminary treatment. If the consti- 
pation be chronic, a few drops (according to the child's age) of the liquid 
extract of cascara sagrada should be given once or twice daily. In some 
cases, especially in robust children, a mineral water, as Carlsbad, may be 
advantageously given two or three times weekly, or magnesia calcinat. in 
lemon-water. 

Infants of one or two years are very liable to intestinal catarrh, especially 
after weaning, and such infants are prone to eczema. These infants should 
receive the treatment which is recommended in another part of this book. 
The diet should be selected and prepared with great care. 

Local Treatment. — The eczematous surface should not be washed with 
plain water, since it is irritating and retards convalescence, and it should not 
be exposed to the air or winds. The exception may be in strumous cases, 
when out-door life may be of service in improving the general health. In 
the first place, the crusts and scales should be entirely removed if possible, 
so that the remedy subsequently applied will reach the surface. Commonly 
a poultice is applied for three or four hours. A better plan is to apply strips 
of flannel soaked with sweet oil until the crusts are softened by the oil, so that 
they can be detached. Or the application may consist of two drachms of 
bicarbonate of sodium added to one quart of the decoction of marsh m allow 
or thin gruel. The oil or poultice should be applied night and morning, and 
the softened and detached crusts removed at each dressing. 

Eczema presents so many different forms that the proper external remedy 
varies in different cases. Generally in acute or subacute forms of the disease 
the applications should be constant. Intermissions in treatment should not 
occur except in the chronic or dry forms of the malady. It is necessary for 
successful treatment to protect the surface from the air, so as to exclude the 
microbes which it contains, for microbes, especially in the foul air of a city, 
irritate the diseased surface and tend to keep up the inflammation. 

Ordinarily, dusting powders or lotions should be preferred. Ointments are 
preferable if the discharge is light, and hard pastes over dry surfaces. When 
there is much hyperaemia and discharge non-irritating antiseptic applications 



964 LOCAL DISEASES. 

are the most useful. It is better ordinarily to employ mild applications in 
the beginning of the treatment of a case until we ascertain how tolerant the 
skin is of remedies. Keratolytic treatment, or such as softens or loosens the 
skin, is required if the eruption be indolent and scaly or much thickening and 
itching be present. The astringent preparations used in the treatment of 
skin diseases are mainly the preparations of zinc, lead, bismuth, boric acid, and 
alum. Among the important antiseptics are resorcin, salicylic acid, ichthyol, 
and its equivalent, thiol. Lotions containing powders in suspension, like 
bismuth, applied to the diseased surface and allowed to dry leave a deposit 
which protects the surface. They are useful when the discharge is slight or 
absent. They should not be applied on parts covered by hair. They relieve 
the itching of a papular eczema, and often will abridge this disease or prevent 
its recurrence if healed. In cases requiring strong lotions, as nitrate of silver, 
permanganate of potassium, or tar, the surface should be painted from one to 
three times daily. 

Soothing applications in the form of liniments or ointments should be 
thickly spread on strips of lint and linen, and they may be reapplied twice 
daily. Stimulating antiseptic ointments, unless quite weak, seldom require 
constant use. They may be applied once or twice daily, and the skin should 
be protected from the air when they are not in use. 

In subacute eczema the following, known as Lassar's soft paste, is useful : 

R. Zinci oxidi, | -- { . 
Pulv. amyli, / ° J ' 

Petrolati, ^ss ; 

Acidi salicylici, gr. x. — Misce. 

Ten or twenty grains of the boric acid may be substituted for the salicylic 
acid. 

A similar paste is Ihle's, having the following formula : 

R. Lanolin, 

Zinci oxidi, • o J > 

Pulv. amyli, J 

Resorcin, gr. x. 

These pastes should be spread thickly on the part and covered by a many- 
tailed bandage of porous cloth. 

The pastes which become firm contain gelatin, glycerin, and zinc. Unna's 
is one of the best of them. It has the following formula : 

R. Gelatini, \ -- . 

Zinci oxidi, ) aa ' 3^f ' 

Glycerini, ^iij ; 

Aquse, 3 iv. — Misce. 

Unna usually adds 2 per cent, of ichthyol, but if this kind of medicine is 
required, thiol, which is the chemical equivalent of ichthyol, may be substi- 
tuted for it, and other antiseptics may be added if needed. These pastes are 
properly used upon surfaces that are dry or with little discharge. The paste 
is heated in a spoon or convenient vessel until it is liquid, when it has the 
consistence of cream. It may be applied with a stiff brush or with the side 
of the finger, and cotton wool daubed upon it to prevent adhesion to the 
clothing. 

If the discharge of an eczematous eruption be considerable, desiccating 
powders are required, as the following : 



DISEASES OF THE SKIN. 965 

R . Zinci oxidi, 1 part ; 

Pulv. amyli (rice or maize), 3 parts. — Misce. 

R. Zinci oxidi, \ , 

Lycopodii, | e q uai P arts - 

R. Bismutlii subnitrat., 5J ; 

Ziiici stearat, gij. — Misce. 

In eczema that is extensive, and not profuse, the surgeon's lint soaked 
with calamine liniment (prepared calamine, 9ij ; zinci oxidi, £ss ; lime-water 
and olive oil, da. 5ss) makes a soothing and effectual application. When the 
discharge is profuse the glycerole of the subacetate of lead 1 : 10, applied 
warm, is one of the best applications. The ammoniated or yellow oxide of 
mercury, gr. 10 to 60, rubbed up with glycerin 1 ounce, is useful for scaly 
patches and for the scalp when the acute stage has abated. Some derma- 
tologists, when the inflammation has considerably abated, add a small amount 
of a mercurial to the soothing ointment employed, as 1 or 2 per cent, of the 
oleate of mercury upon localized patches. 

In pustular eczema iodoform or aristol is the most efficient agent for local 
use. From 5 to 10 grains of this added to any astringent ointment, such as 
zinc or lead, quickly destroy the cocci of pus, so that the eruption soon 
becomes serous or dry. I have obtained benefit by applying sweet oil over 
the pustular patches and dusting aristol over the oil. 

Tar is a useful remedy if applied at the right stage or in the right form 
of eczema. Its use is not indicated, and it may do harm, in acute eczema. 
It is most useful in the squamous and papular forms, effectually relieving the 
irritation, as in the following formula : 

R. Olei picis liquidse, 3 SS- 5J '■> 

Olei cadini, rr^v ; 

Ung. aquae rosse, ^ij. — Misce. 
Apply three or four times daily. 

Eczema is so common that it will aid the physician to call to mind the 
mode of treating different forms of it by prominent dermatologists. White 
of Boston and Duhring of Philadelphia employ for acute eczema the lotio 
nigra, either of the full strength or diluted with an equal quantity of water. 
It is applied with a sponge or a wad of absorbent cotton for a quarter of an 
hour. The black powder is allowed to remain on, and then a little zinc oint- 
ment is smeared over it, and this is repeated every three or four hours. 

Unna of Hamburg strongly recommends ichthyol, applied externally, in 
eczema. As an ointment or lotion of the strength of 5 to 50 per cent, it is 
applied on the moist obstinate patches which often occur on the hands and 
arms. Used in the percentage mentioned, a good vehicle for it is Unna's zinc 
paste mentioned above. Thiol, which has the same chemical characters as 
ichthyol, may be used in place of the latter, as it is less offensive. 

A very important part of Crocker's recent treatise on skin diseases, which 
two prominent New York dermatologists inform me is the best book yet 
published in this branch of medicine, relates to the regional treatment of 
eczema. His remarks on this subject I will condense, as follows: 

Eczema of the Head. — Cut the hair short. Soften the crusts with strips 
of flannel dipped in oil, and fasten them on with a calico cap for four to six 
hours. The crusts may then be removed. If the disease be eczema pustu- 
losum, gr. v of iodoform to ^j of vaseline on strips of lint should be kept 
on with the cap, and renewed morning and evening. The old ointment 
should be wiped off. In a week the eruption will be serous or dry instead 



966 LOCAL DISEASES. 

of pustular. Oleate of zinc or lead or boracic acid, gss to ^j, should then 
be substituted in place of the iodoform, with perhaps later the addition of a 
few grains of amnioniated mercury. 

In eczema vesiculosum these ointments should be used at once. Where 
there is much irritation a few minims of the oil of cade to the ounce is a 
good addition, and the hairs should be extracted if there is pustular inflam- 
mation around them. 

Eczema of the Ears. — Calamine liniment (prepared calamine, 9ij ; zinci 
oxidi, £ss ; lime-water and olive oil, da. gss), freely applied and painted inside 
the meatus several times daily, gives most relief. The lactate-of-lead lotion 
(subacetate of lead, 33, and fresh milk, §ij), shaken well in the bottle, or the 
glycerole of the subacetate of lead (subacetate of lead 1 part, and glycerin 
10 parts) is also a good application. 

Eczema of the Face. — In infants this is common. The following remedies 
are useful for external treatment : Lassar's paste, described above, or the 
lead, zinc, or boracic-acid ointment. (The lead ointment is made by boiling 
together equal parts of diachylon and sweet oil.) The boric-acid ointment 
consists of finely-powdered boric acid, gss, and benzoated lard, gj ; and Wil- 
son's " ung. zinci oxidi benzoat.," much employed for eczema, consists of 
prepared lard, ^iij ; powdered benzoin, gss. Melt together at a gentle heat 
for twenty-four hours in a closed vessel, strain, and add oxide of zinc, ^j. 
The chief difficulty is to prevent scratching, and to accomplish this almond 
oil should be applied under the dressing, and, if necessary, the hands secured 
to the sides of the patient. 

Eczema of the eyelids (blepharitis), common in the scrofulous, has long 
been successfully treated by the application of weak mercurial ointments. 
The crusts should be softened with oil and removed, after which 1 part of 
the ung. hydrarg. nitratis and 8 parts of vaseline should be smeared along 
the edges. In the strumous the syrup of the iodide of iron should be em- 
ployed. 

Eczema of the lips sometimes leads to fissures resulting from the frequent 
motion. The liq. plumbi subacetatis, tt^xv, mixed with white vaseline or 
lard, should be prescribed for application over the lips, or, if this be inade- 
quate, the following formula, recommended by Hebra, may be cautiously 
painted on : 

R. Acidi carbolici, ,^ij ; 

Glycerini, ") _ -. 

Athens, } aa ' 3J J 
Spts. vini recti, ^vj. — Misce. 

Though having the utmost confidence in Hebra's opinion, I think, on account 
of the highly irritating nature of carbolic acid, that it would be judicious to 
employ only ^ss of this agent in the above prescription for children, or not 
use it, but wait for the slower action of milder measures. 

Eczema of the Palms. — In all instances it is necessary to remove the 
thick epidermis. The hard and thickened skin may be rubbed by pumice- 
stone or fine sand-paper. Unna's plan of employing salicylic-acid plaster, 
applied fresh every two or three days, is good. The thickened epidermis 
may be peeled off in this manner. The disintegration and removal may also 
be produced by the constant application of a pancreatic emulsion. 

When the epidermis is removed salicylic acid, gr. x to lx, added to ^j of 
the gelatin-zinc paste, which is useful as a base, should be applied, and re- 
newed once in twenty -four hours. Thiol and ichthyol are also said to have a 
good effect in diminishing the thickness of the epidermis, but if either be 



DISEASES OF THE SKIN. 967 

used it should be with the salicylic acid, the efficacy of which in diminishing 
the thickness of the epidermis is well known. 

Eczema of the Xails. — This disease is somewhat protracted on account of 
the difficulty in applying remedies around the matrix. A useful remedy is — 

R. Aristol, 5j; 

Olei oliva?, ^iij ; 

Lanolin, ,§j- — Misce. 

A good remedy also is salicylic acid, 5J, mixed with sweet oil, ]§ss, and 
lanolin, §j. 

Eczema genitalia of the scrotum, genitalia, and other contiguous parts 
sometimes occurs. All causes which might excite this inflammation should 
be removed, and calamine liniment be applied, not by rubbing, but upon sur- 
geon's lint soaked with it or a thin layer of absorbent cotton, which for pur- 
poses of cleanliness may be covered with oil-silk. Bulkley recommends 
applying, before the liniment is used, a handkerchief dipped in water as hot 
as can be borne for two or three minutes. 

The Pathogenic Effects of Microbes. 

Recent microscopic examinations have almost conclusively demonstrated 
the fact that various diseases presenting different clinical histories are pro- 
duced by the entrance of microbes into the cutaneous tissue. 

Impetigo Contagiosa. — This consists of discrete vesicles or pustules due 
to contagious pus, and occurs most frequently in children of the poor and in 
those who are cachectic and who live in disregard of sanitary requirements. 
Occurring frequently in an epidemic form, crops of vesicles appear for several 
days, with mild fever, the disease abating in about two weeks. In some 
instances this disease has no fever and no definite course, but the eruption 
occurs chiefly around the mouth, chin, nostrils, and occipital regions. Two 
or more vesicles or pustules may unite, forming one of larger size, but the 
discrete eruption is also present in adjacent parts. The initial stage in this 
disease is vesicular. The vesicles are as large as a pea or larger, but they 
soon become pustular, flat, and irregular. 

Impetigo contagiosa varies greatly in extent and severity. There may 
be a few distinct eruptions, or they may unite in extended patches, spreading 
over the body. Under such circumstances the vesicular form predominates. 

When the disease occurs upon the limbs, the vesicles or pustules are 
liable to be broken and become scabbed, and the surrounding surface forms 
an areola. This has been designated ecthyma, but the more typical eruption 
on the face shows that the eruption on the limbs is an impetigo contagiosa 
changed by friction. 

Etiology. — The theory that impetigo contagiosa is produced by conta- 
gious pus is now accepted by dermatologists. Scratching readily produces 
the transference of the contagious principle from one place to another. It 
appears to be most frequently and abundantly produced in the cachectic and 
poorly nourished. Of four hundred children with this disease observed by 
the late Mr. Startin, three-fourths were children under the age of seven 
years. 

Pathology. — The fact that impetigo contagiosa is undoubtedly conta- 
gious, as its name implies, leads to the belief that its cause is microbic. 
Crocker found in the liquid cautiously withdrawn from unbroken vesicles 
and pustules, chains of micrococci in twos and multiples of twos. They were 
most abundant in pustules and in the margins of epithelial cells, but not in 



968 LOCAL DISEASES. 

the pus-cells. The liquid was withdrawn in a capillary tube and blown upon 
the cover-glass. E. A. Barton obtained pure cultures of staphylococcus 
pyogenes aureus from the fluid of unbroken vesicles, and Dubreuilh of Bor- 
deaux and others in independent examinations have discovered the same 
organism, so that the theory may be considered established that this disease 
is caused by the streptococcus. 

Diagnosis. — The absence of redness around the eruption unless it be 
rubbed, and the inoculability of the liquid in the vesicles or pustules, are 
diagnostic. 

Prognosis. — The disease with correct treatment will not continue more 
than two or three weeks, but if neglected the contagiousness of the eruption 
and its inoculability may cause its continuance for an indefinite time. 

Treatment. — The crusts should be soaked in sweet oil until they can be 
detached. After they are removed the following ointment should be con- 
stantly applied, and the cure soon results : 

R. Hydrarg. ammoniati, gr. x ; 

Cerat. simplic, ^j. — Misce. 

Seborrhcea. — This term, as the name indicates, is applied to an increased 
flow of the secretion from the sebaceous glands. The sebaceous substance 
undergoes some alteration in consistence in different instances, so as to form 
oily, waxy, or scaly concretions upon the surface. The purpose of the seba- 
ceous matter or sebum is to lubricate the skin, and the glands which furnish 
it occur upon nearly every part of the surface, except the palms of the hands 
and soles of the feet. Although the sebaceous glands are so numerous, it is 
difficult to collect sufficient sebum for microscopic examination. Lutz pub- 
lishes the following mean of eight analyses of this substance taken from a 
case of general hypertrophy of the sebaceous system : l 

Water 357 

Oleine 270 

Margarine 135 

Butvric acid and butvrate of soda 3 

Casein ^ * 129 

Albumin . 2 

Gelatin 87 

Phosphate of soda and traces of phosphate of lime 7 

Chloride of sodium 5 

Sulphate of soda 5 

Seborrhea sicca is a term applied to the waxy and scaly forms. These 
forms may be associated or pass into each other, and they are regarded as 
the chief cause of premature baldness. The oleaginous ingredients of the 
sebum render the skin supple and glossy. 

The waxy form varies according to the location and the age. The vernix 
caseosa of the new-born is regarded as sebum of the waxy form. In the nor- 
mal state the sebaceous material is abundantly secreted in infancy, and it 
often accumulates upon the scalp, chiefly at the vertex, where it forms a yel- 
lowish mass which collects dust and dirt. It is sometimes quite thick and of 
a caseous consistence. The skin underneath has a healthy appearance, unless 
it be irritated by decomposition of the oleaginous matter, when it becomes 
inflamed and an eczema results. 

The secretion which collects under a narrow and long prepuce in the male 
child, and around the clitoris and between the labia in the female, when proper 
ablution cannot be or is not performed, consists of epithelial cells and seba- 

1 Flint's Physiology. 



DISEASES OF THE SKIN. 969 

ceous matter, and its irritating property is very likely to cause inflammation, 
a balanitis, or a vulvitis, according to the sex. All physicians who have per- 
formed the simple operation of stretching the prepuce, so as to expose the 
glans in order to remove the irritating smegma, or have performed the more 
severe operation of circumcision, know how frequently a catarrhal inflamma- 
tion has been excited by the smegma, so as to cause a vascular adhesion of 
the prepuce to the glans. This inflammation is produced by the decomposing 
epithelial cells and smegma. 

The relation of the sebaceous glands and the hair-follicles is intimate. 
The sebaceous glands are racemose — that is, existing in distinct lobules, 
which discharge their contents into a common duct, and this duct opens into 
the hair-follicle at about the junction of its upper third with the lower two- 
thirds. From two to five of these racemose glands are arranged around each 
large follicle. 

The effect of the waxy form of seborrhoea when the secretion is sufficient 
to form a crust of a yellow, dirty appearance is to distend and plug the hair- 
follicles. This leads to atrophy of the hair and premature baldness. 

Seborrhoea furfur acea, or the scaly form, has been designated by the terms 
pityriasis simplex, dandruff, etc. Many, more frequently adults than children, 
have their scalp constantly covered with white, fine, shining crusts which are 
readily detached by the hair-brush, so as to alight like small flakes upon their 
clothes. When this form of seborrhoea occurs upon the scalp it occupies 
the same position as the waxy secretion, and, like the latter, may lead to 
baldness. The scalp underneath may be of normal appearance, but it may 
be red and itch or burn from more or less inflammation which has been estab- 
lished. In children seborrhoea furfuracea, exhibiting small shining scales, 
may occur over nearly the entire body and limbs. Such children exhibit 
often .symptoms of the strumous cachexia. 

Seborrhoea universalis is more rare than the local disease. One form of it 
is the vernix caseosa which covers the body of the new-born, and continues 
to be secreted until the infant is a few days old. It sometimes gives rise to 
tension of the skin and fissures. If the whole integument is affected, it may 
shine as if varnished. Fissures, painful when moved or touched, arise from 
the angles of the mouth, upon the joints, and in the gluteal folds. The 
rigidity of the mouth and nose and the pain of the fissures may render trac- 
tion of the nipple insufficient for the infant's nutrition. Kaposi says : " The 
children die in a few days from inanition and loss of heat unless relief is 
afforded by inunction and softening of the incrustations and by artificial 
maintenance of the heat of the body. This condition is correctly termed 
1 ichthyosis sebacea ' or ' seborrhoea squamosa neonatorum.' " Although the 
skin, when the sebaceous material is removed, appears normal or slightly 
reddened, we find openings of the glands on close inspection, which corre- 
spond with the hair-follicles, into which thread-like prolongations extend. 

Seborrhoea of the scalp may be mistaken for any of those diseases in 
which scales and crusts form upon this part. Especially, it may be mistaken 
for eczema squamosum or impetiginosum, but in eczema the skin of the 
affected part is red and moist, while in seborrhoea it is white and dry. More- 
over, the eruption which is characteristic of the form of disease present occurs 
also often upon other parts. In psoriasis, for which seborrhoea may also be 
mistaken, the eruption always presents a well-defined patch, and the scales 
are abundant, larger, and more firmly attached than in seborrhoea, while the 
surface is very red. Psoriasis occurs not only upon the scalp, but likewise 
usually upon the exposed surfaces, where this eruption can be more easily 
differentiated. Favus and herpes tonsurans are caused by fungi which the 
microscope reveals, and which are never present in seborrhoea. 



970 LOCAL DISEASES. 

Prognosis. — This is favorable in seborrhea, both in its local and general 
forms. Most cases with correct treatment soon improve, and can be perma- 
nently cured. The disease has no ill effect upon the constitution, but is 
sometimes painful from the rhagades and tension, and, besides the unsightly 
appearance which it produces, it may be complicated by eczema, comedoes, 
and acne upon conspicuous parts like the features. 

Treatment. — We have to deal with epidermis, crusts of fat, scales, and 
secondary deposits of morbid products. First of all, they must be softened, 
detached, and removed. They are softened and detached most rapidly and 
effectually by the fluid fats, and are then removed by the action of soap and 
water. For this purpose as domestic remedies butter and lard have been 
used, and physicians have obtained the desired result by rubbing in warm 
vaseline, cod-liver oil, or sweet oil. Upon the scalp, which is the most com- 
mon seat of seborrhoea in infants, the oil is best rubbed in by a pledget of 
lint, a small sponge, or a firm brush, sufficient pressure and friction being 
used to cause permeation of the crust, and the head is then covered by a cap 
of flannel or other suitable substance. In this manner the oil is applied four 
or five times daily, and allowed to remain on over night. Within a day or 
two the crusts become soft, friable, and broken, so as to be readily detached. 
When this occurs they are gently removed by washing. 

In infants attempts to remove the sebaceous matter should be performed 
gently, and not until the scabs are completely softened and broken ; in adults 
the process may be expedited by cutting the hair. 

When the crusts are softened and disintegrating, glycerin soap is prefer- 
able for cleansing the tender surface of infants, as it is less irritating than the 
ordinary toilet soap. In older children, as well as in adults, the following 
formula from Hebra is useful in cleaning the surface after it has undergone 
the treatment mentioned above : 

R. Saponis viridis, 100 grammes ; 

Solve leni calore in spir. vini, 200 ' ' 
Filtre et adde — 

Olei lavenduke, "I -- o a 

Olei bergamoti, J aa " 6 

Misce. Filtra. 

A coarse flannel cloth or a sponge is used for making the application, with 
an abundance of lukewarm water. By the thorough ablution performed in 
this way affected parts are entirely cleaned, when they should be dried. By 
this mode of treating seborrhoea hairs that are held together by the crusts 
are often detached, and patients sometimes attribute the baldness which 
results to the treatment. The seborrheal process, however, caused the 
detachment of the hair and more or less baldness. 

The skin when cleaned by the method described appears red, but the 
redness fades under proper treatment, and the unpleasant sensation, fissures 
of the thin corium, and reproduction of the sebaceous deposits are prevented 
by applying oily substances. Kaposi recommends the following after the 
skin has lost its tenderness and the corium has regained its thickness. The 
application must be made for several weeks to the scalp of spiritus vini gallici r 
either used pure or in the following formula : 

R. Acidi carbolici, 0.15; 

Acidi borici, 3.00 ; 

or Acidi salicylici, 3.00 ; 

Spts. vini gallici, qs. ad 100.00. — Misce. 

Inasmuch as the treatment of the corium by soap and alcohol tends to 



DISEASES OF THE SKIN. 971 

render it brittle, it is befst in the subsequent treatment to apply some bland 
oil or fat for weeks or perhaps months. 

General seborrhoea must be treated in the same manner as local forms 
of it, allowance being made for the age. The cutis testacea (ichthyosis 
sebacea neonatorum) requires vigorous rubbing of the surface with sweet 
oil, or the application of cloths soaked with a bland ointment and applied 
over the face, limbs, body, fingers, and toes, and retained by a flannel binder. 
The infant is kept in an incubator or in a poor conductor of heat, as down or 
flannel. It should be washed daily in a warm bath with glycerin soap, after 
which the oil is applied. 

Parasites of the Skin. 

A complete treatise on diseases of the cutaneous system requires the 
description of a considerable number of vegetable and animal parasites which 
grow upon or burrow in the skin. It is our purpose to describe only such 
as occur most frequently in America. The parasitic diseases are observed 
chiefly among the filthy who seldom bathe or change their clothes. The 
most common of these diseases is — 

Scabies, or the Itch. — This is contagious by contact or transference. It 
is caused by a minute animal parasite, and its chief lesions are the burrows 
produced by the female in order to deposit her eggs, and such injuries as 
result from the scratching due to the intense itching incident to the burrow- 
ing. The itch-mite, or acarus scabiei, consists of the male and female, and 
the symptoms and lesions are mainly due to the latter, which when removed 
from its burrow is barely visible to the naked eye as a minute yellowish- 
white hemispherical body. Viewed under the microscope, it is seen to be 
crab-like, with legs and a proboscis ; the rounded body has wavy transverse 
furrows, so that the parts move over each other with facility. From obser- 
vations made by Eichstedt, Guddens, and others, the female has been found 
within half an hour after being placed upon the skin to have concealed her- 
self in the epidermis, and the burrow which she constructs is arched, tortuous, 
and four or five lines in length. The young acarus has six, the mature eight, 
articulated legs, with suckers upon the two anterior pairs and hairs on the 
posterior. The head, which can be elongated or retracted, is provided with 
two jaws. The upper surface is covered with spines directed backward so as 
to prevent retrogression in the burrow. She leaves behind her in the cunic- 
ulus, as she advances, her moulted skin, excreta, and eggs, which hatch on 
the eleventh day. The mother-acarus is always found at the remote end of 
the burrow, where it can be seen by the unassisted eye as a minute whitish 
or sometimes brownish speck, and from which it can be lifted by the point 
of a needle, to which it clings. The cuniculi can also be seen by the naked 
eye, looking, says Niemeyer, like the " scars of needle-scratches." and con- 
taining the young acari in various stages of growth. 

The acarus by its burrowing produces an irritation and troublesome itch- 
ing, which is the chief cause of the suffering of the patient. At the point 
where the acarus penetrates the cuticle the inflammation gives rise to a single, 
small, and acuminate vesicular or papular eruption, the cuniculus extending 
away from it. We often find ecthymatous pustules and abrasions intermin- 
gled with the vesicles, the result of frequent scratching. The itching is most 
intense and the acarus most active at night, when the patient is warm in bed. 
Scabies most frequently appears, especially in adults, first upon the hands, 
between the fingers, where the skin is thin, and it extends thence along the 
forearm and over the thighs and abdomen. In children it not infrequently 
occurs upon the buttocks, thighs, feet, etc., while the hands and forearms escape. 



972 



LOCAL DISEASES. 



Fig. 269. 



Fig. 270. 




Fig. 269. The itch animalcule, Acarus scabiei, viewed upon the back, showing its figure and the 
arrangement of its spines and filaments. The female, which is somewhat larger than the 
male, has a length of one-eightieth to one-sixtieth of an inch. 

Fig. 270. The foot and last joints of the leg of the itch animalcule. 

Fig. 271. Ova of the itch animalcule. 

Fig. 272. The male itch animalcule, viewed upon the under surface, showing its legs and 
lobuiated feet. 

Fig. 273. Burrow of the female acarus (after Kaposi). 

Diagnosis. — Correct diagnosis is important, because the treatment 
required is different from that in any other exanthem, and because the 



DISEASES OF THE SKIN. 973 

suspicion of having this disease always renders one solicitous to know the 
exact nature of the eruption. Scabies can be diagnosticated from those dis- 
eases for which it may be mistaken by the following characters : its occur- 
rence where the cuticle is thin and delicate, as between the fingers, along the 
anterior aspect of the forearm, upon the abdomen, thighs, and inside of the 
feet : small size, acuminate shape, and isolated position of vesicles ; the inter- 
mingling with the vesicles of other forms of eruption, as papules and pustules, 
and the presence of linear scars and abrasions produced by the scratching ; 
itching most intense at night ; absence of fever ; absence of the disease from 
posterior aspect of body and arms and from head and face. Scabies may be 
distinguished by the vesicular character of the eruption from all other exan- 
thematic affections except eczema, sudamina, and herpes. Eczema is most 
common on the scalp and face, where scabies does not occur, and unlike 
scabies its vesicles are round and thickly aggregated in clusters ; in eczema 
there is a smarting or prickling sensation very different from the intense itch- 
ing of scabies. In herpes the vesicles are large, rounded, and in clusters, 
and attended by a burning or prickling sensation, with but little itching. The 
eruption in sudamina is vesicular and discrete, as in scabies, but it is globular 
and accompanied by no itching or other local symptoms. 

Treatment. — As scabies is due to a species of acarus which burrows in 
the epidermis, it can only be treated successfully by measures which destroy 
this animalcule. If it be destroyed, the disease gets well of itself. Sulphur 
has been employed for a long period for this purpose, since sulphurous acid, 
which is evolved from the sulphur, is destructive to the animalcule. The 
unguentum sulphuris, if thoroughly applied, will rarely fail to eradicate sca- 
bies. The internal use of sulphur aids the external treatment, since a portion 
of the gas which is generated escapes through the pores of the skin. The 
chief objection to the employment of sulphur is its exceedingly unpleasant 
odor, which is noticeable, however disguised by perfume. Sulphur or any 
other substance employed externally has more effect if it be preceded by a 
bath, which softens the epidermis, and therefore favors the entrance of the 
remedy into the pores of the skin and the cuniculi. 

Helmerich's ointment is very effectual in the treatment of scabies. It 
consists of two parts of sulphur, one of carbonate of potassium, and eight 
of lard. " M. Hardy afterward perfected the method, so as radically to cure 
the disease in two hours. He proceeded in the following manner : The patient 
first undergoes a friction of his whole body for half an hour with soft soap, 
in order to cleanse the skin and break up the burrows ; a warm bath of an 
hour's duration follows, during which the skin is thoroughly rubbed, in order 
to complete the destruction of the burrows ; after which frictions for half an 
hour and upon the whole surface are practised with Helmerich's ointment. 
This completes the cure. Out of 400 patients subjected to this treatment 
only 4 returned to the hospital." l 

M. Albin Gras experimented with different substances in order to ascer- 
tain their relative destructiveness to the acarus. The following table gives 
some of the results of his experiments : 

Immersed in pure water, the acarus was alive after three hours. 

saline water, the acarus moved freely after three hours. 
Goulard' s solution, the acarus lived after one hour, 
olive, almond, or castor oil, the acarus lived more than two hours, 
lime-water, the acarus died in three-fourths of an hour, 
vinegar, " twenty minutes, 

alcohol, 
" turpentine, " " nine " 

iodide of potassium, the acarus died in four to six minutes. 

1 Stille's Therapeutics, etc., vol. ii. p. 561. 



974 LOCAL DISEASES. 

It is seen that vinegar, lime-water, alcohol, turpentine, and iodide of 
potassium destroy the acarus in a short time. They may be employed in 
the same manner as the sulphur ointment. Camphor is also destructive to 
this animalcule, and the linimentum camphorse, thoroughly applied, is a good 
remedy for uncomplicated scabies. 

In order to avoid the odor of sulphur, which is so offensive, one of the 
following ointments may be employed if the patient be fastidious: 

R. Unguent, hydrarg. ammoniat. , ^j ; 

Moschi, gr. ij ; 

01. lavendul., gtt. ij ; 

01. amygdal., 3j. — Misce. 1 

If scabies be extensive, this should not be used, as its application over a 
considerable area might endanger salivation, but the following, which is rec- 
ommended by Bazin, and is said to cure the disease with three applications, 
may be used instead : 

R. Anthemis pulv., 
Adipis, 
01. olivse, da. ^j. — Misce. 

In cases which have been protracted, and in which ecthymatous and other 
secondary eruption have occurred, the scabies can ordinarily be readily cured, 
while the other eruptions remain and disappear more slowly. A knowledge 
of this is important, since the sulphur or other ointment employed for the 
cure of scabies should be discontinued when the itching ceases and vesicles 
no longer appear, and tonic or other treatment appropriate to cure these 
secondary eruptions should be employed instead. The sulphur ointment 
continued after the scabies is cured does harm, since it irritates the cuticle. It 
is essential in the treatment of scabies that the linen be frequently changed. 

Pediculosis. — The pediculi, or, in common parlance, lice, " are wingless 
insects without metamorphosis, with two simple small eyes. They first bite 
into the skin with their mandibles, and then insert the head into the wound 
in order to suck " (Kaposi). Three varieties of these insects inhabit the sur- 
face of man. The one abides upon the scalp, the second in the vestments, 
and the third upon the pubes. Hence the classification — 

1. The pediculus capitis ; 

2. The pediculus vestimenti ; 

3. The pediculus pubis. 

The piercing of the skin with the mandibles, the suction of the blood 
and serum, and the formation of crusts or wheals cause intense itching with 
scratching. Hence result excoriations, vesicles, papules, furuncles, abscesses, 
crusts, which produce a resemblance to certain other eruptive diseases, but 
which are chiefly due to the intense itching and unavoidable scratching. The 
lesions of course vary according to the number and variety of the pediculi 
and the duration of the disease. 

The three varieties of pediculi seldom wander from the regions which 
they primarily occupy. The first variety rarely pass beyond the scalp ; 
the second variety occupy the folds of the vestments, to which they suddenly 
retreat when the garments are disturbed ; and the third variety seldom leave 
the pubic region. 

The pediculus capitis has the length of two millimetres, and is of a gray 
color ; its head and limbs are thicker and chest broader than are those of the 
pediculus vestimenti. 

1 From Wilson. 



DISEASES OF THE SKIN. 975 

Treatment. — In the treatment of pediculosis capitis the use of petro- 
leum according to the following formula will be found safe and effectual : 



R. Petrolei, 


100 parts ; 


01. oliva?, 


50 " 


BaJs. Peru, 


20 " 


Rub freely into the hair. 





If there be moderate eczema, naphthol oil, 5 per cent., may then be 
applied, and the head wrapped in flannel. In twenty -four hours the lice are 
dead, and the nits, which are attached to the hairs at different distances, are 
incapable of growth. The scalp is then washed with the spiritus saponatus 
kalinus. prepared according to the following formula of Hebra : 

R. Saponis viridis, 100 grammes ; 

Solve leni calore in spir. vini, 200 " 
Filtra et adde — 
Olei lavendulae, 
01 ei bergamoti, da. 3 " 

The eczematous crusts which occur from the irritation and scratching in 
pediculosis are softened and broken up by this treatment. Daily oiling and 
washing the surface complete the cure. 

The treatment of pediculosis corporis by a complete change of clothing 
and a bath of the entire surface with soap and water speedily cures the dis- 
ease, since the insect which causes this form of pediculosis lives in the vest- 
ments. Of course the worn clothes should be burnt. 

Pediculosis pubis is cured by applications which destroy the insect, among 
which we may mention 1 part of corrosive sublimate to 250 of water, and by 
naphthol, as well as by petroleum. The nits are destroyed by carbolic acid, 
1 part to 50 of water. 

FORMULARY. 

Within the last few years the investigations of dermatologists have 
revealed the important causal relation of bacteria to the cutaneous diseases. 
Unna believes that eczema, which is probably the most common cutaneous 
malady of early life, is parasitic, " due to some micrococcus not yet deter- 
mined," and he adduces the success of antiseptic local treatment as a proof 
of this theory. Crocker says : ' c My own view is this : that while a limited 
number of local skin diseases are parasitic, in most the dermatitis, however 
caused, only opens the door to parasites, whose presence keeps up local irri- 
tation, and that their destruction is an important step in the restoration of 
the skin ad integrum." Again Crocker writes : " . . . . Micrococci are so 
ubiquitous that their invariable presence may be demonstrated in any par- 
ticular disease ' : of the skin. Hence germicides are regarded as important 
agents in the initial treatment, as well as during the progress of those mal- 
adies in which the cuticle is so injured by disease that it no longer prevents 
the invasion of microbes. 

The lotio nigra is one of the best, if not the best, germicide wash employed 
for this purpose. 1 drachm of calomel is mixed with 1 pint of lime-water, 
and by double decomposition the very active and safe germicide calcium 
chloride and the oxide of mercury are produced. The former is the anti- 
septic required. By the judicious use of this remedy, followed by an oint- 
ment like Lassar's, many of the acute eczemas rapidly yield. 

The following formulae, most of which have been obtained from Crocker's 
and Kaposi's recent treatises, will be found useful to the practitioner : 



976 



LOCAL DISEASES. 



Baths. 

1. Cold, 40°- 65° Fahr. 

2. Cool, 65°- 75° " 

3. Tepid, 85°- 95° " 

4. Warm, 95°-100° " 

Lotions. 



5. R. Hyd. chlor. corros., 


g r - ij ; 


Tine, benzoin., 


3 ss ; 


Misturae amygdalae, 


%— M. 


For freckles (Duhring). 




6. R. Hyd. chlor. corros., 


gr. vj ; 


Acidi aceti dilut., 


3ij ; 


Sodii borat., 


9ij ; 


Aquae rosae, 


5iv.— M. 


For freckles (Bulkley ) . Apply twice daily 


7. R. Corrosive sublimate, 


gr. iv ; 


Dilute nitric acid, 


3J; 
3J ; 


Dilute hydrocyanic acid. 


Glycerin, 


|;viij. — M. 


For syphilitic eruptions, pityriasis versic- 


olor, chloasma, freckles (Startin 


)• 


Soft Soap. 




8. R . Oil of cade, ] 




Soft soap, V da 


gss; 


Alcohol, J 




Olive oil, 


Ijss; 



Oil of lavender, 3Jss. — M. 

For chronic eczema, psoriasis of the scalp 
or knee. 
9. R. Soft soap or green soap, alcohol, 
equal parts. — M. 
To remove scales of psoriasis and sebor- 
rhoea. 

Sulphur. 

10. E. Sulphur precipitat, 

Alcohol, 
For acne. 

11. R. Sulphur, "1 

Alcohol, 
Ether, 
Glycerin, 
Carb. potash, 
Rose-water, 
For acne, or, without the water, rubbed 
in, for comedones. 

12. R. Potassium sulphuret, £ss ; 

Lime-water, 3 x vj. — M. 

For pustular and parasitic diseases and 
pityriasis versicolor. 

13. R. Sulphuris loti, 3J ; 

iEtheris, f £>iv ; 

Alcoholis, f^iijss.— M. 

Shake bottle, and apply with a swab of 
cotton every three or four hours. 

For acne I have used this with a good 
result. 

14. R. Lime-water, 

Olive or linseed oil, ad. — M. 

For burns and superficial inflammations 
of skin. 



da. £j.— M. 



da. ^ij ; 



^viij.— M. 



15. R. Prepared calamine, ^ij ; 

Zinci oxidi, ^ss ; 

Lime-water, olive oil, da. ^ss. — M. 
For eczema and acute dermatitis. The 
parts are wrapped with this lotion. 

16. R. Menthol, chloral, camphor, equal 

parts. Triturated to liquefaction. 
Apply for pruritus and superficial pains. 

17. Tar. 

The liquor carbonis detergens has recently 
come into use as an eligible preparation for 
certain skin diseases. It is designated in one 
of the books as an alcoholic solution of coal- 
tar. 

The following formulae are used for 
chronic eczema and pruritus : 

18. R. Liq. carb. detergentis, f ^ss ; 

Acidi nitrici dilut., gj ; 

Aquae camphorae, ad ^viij. — M. 

19. R . Liq. carb. detergentis, ^j-ij ; 

Liq. plumbi subacetatis, <5J-ij ; 
Aquae rosae, ,§ viij. — M. 

20. Liq. carbonis detergentis, diluted, 1 part 

to 40 or 80 of spirit or water. — M. 

21. R . Ung. picis (B. P.). 

22. R. (a) Creosote, "] gj or more of 

(b) Olei cadini, I either to ^j 

(c) 01. rusci, J of lard.— M. 
Useful in psoriasis and chronic inflam- 
mations. 

Astringent Lotions. 

23. Collodion (non-flexible). 

It acts by mechanical compression, and 
is useful when such is required, as in acne 
rosacea, lupus erythematosus, and in small 
naevi. 

24. Tincture of hamamelis, 1 part to 4 of 

water. 
For dilated capillaries. 

25. R. Tannic acid, gr. xl ; 

French vinegar, ,^ss ; 
Water, ,^vij. — M. 

For seborrhcea and hyperidrosis. 

26. R. Boric acid, a saturated solution. 
For eczema and erythema. 

Stimulants for the Scalp, or Hair 
Lotions. 
The following formulae are given for 
children of half the strength which is 
recommended by distinguished dermatol- 
ogists for adults : 

27. R. Tine, of cantharides, 5ss; 



28. 



For seborrhoea capitis and alopecia. 



Distilled vinegar, 


.^iijss ; 


Rose-water, 


ad §viij— M 


. Hyd. chlor. corros., 


gr. ij ; 


Ammon. chloridi, 


gr. x; 


Resorcin, 


gr. xx ; 


Eau de Cologne, 


Eiy, 


Glycerin, 


&y, 


Aquae rosae, 


to Oj.— M. 



FORMULARY. 



977 



Sedative Astringent Lotions. 
Zinc or Calamine Lotion, 
Prepared as follows : 

29. R. Powdered calamine (the na- 

tive carbonate of zinc), ^ij ; 
Oxide of zinc, £ss ; 

Glycerin, w\,xv ; 

Eose- water, 5 j . — M. 

For erythema and eczema when little or 
no discharge, and for active hyperaemic 
states. 

Bismuth Lotion. 

30. R • Bismuth, subnitrat. , gr. viij I 

Oxide of zinc, gss ; 

Glycerin, ^^vj ; 
Hydrarg. chlor. corros., gr. J ; 

Eose- water, ^ j . — M. 
For acne rosacea and other hyperaemic 
states. 

Lead Lotion. 

31. R. Solution of subacetate of 

lead, ir b v-xx ; 

Glvcerin, Ti\,xv ; 

Water, gj — M. 

For erythema, eczema, and excoriations. 

Sedative Astringent Ointments. 
Boric Acid. 

32. R. Boric acid, ^ss ; 

Benzoated lard, Jj. — M. 

The boric acid should be ground into an 
impalpable powder before the admixture. 

Used in eczema and as an antiseptic in 
wounds and excoriations. 

Lead. 

33. R. Carbonate of lead, gr. iv ; 

Glycerin, 3j ; 

Simple ointment, Jj. — M. 

For erythema. 

Zinc. 

Wilson' s benzoated zinc ointment, a well- 
known remedy for eczema, is prepared as 
follows : 

34. R. Lard, ^vj ; 

Powdered benzoin, gj. — M. 

Melt together for twenty-four hours at a 

gentle heat in a closed vessel, and then 

strain and add oxide of zinc ^j. Stir till 

cool and strain. 

Antiseptic Ointments. 

35. R. Iodoform, gr. iij-v ; 

Vaselin or lard, ^j. — M. 

To cover the unpleasant odor of iodo- 
form, creolin n^v to 5J may be added. 

36. R. Aristol, gr. iij-v ; 

Vaselin or lard, §j.— M. 

Aristol, used in powder, is also very 
effectual in curing sores and the surround- 
ing inflamed tissue. 

62 



Mercury. 

37. R. Ammoniated mercury, gr. x ; 

Lard, fj.— M. 

A specific for impetigo contagiosa after 
the crusts are broken. 

Sulphur. 

38. R. Iodide of sulphur, gr. x to 3ss, 
added to lard, 5J. — M. 

For acne. 

Antipruritic Lotions. 



39. R. Borax, 

Glycerin, 
Water, 
Use in urticaria 
seborrhoea. 


£ss; 
Oij.- 
and as a 


-M. 

head-wash in 


40. R. 


Borax, 

Carbonate of ammo- 






nia, da. 3iss ; 
Glycerin, Jj ; 
Hydrocyanic acid, 

dilute, sjiij ; 
Water, S vn j- — M. 



Use diluted one to four times. 

For vesicular diseases and seborrhoea. 

41. R. Acidi carbolici, £j ; 

Tinct. camphorae, Jij ; 

Aquae, Oj.— M. 

An excellent application to the surface 
in pruritus of any kind, provided that the 
skin be not broken. 

42. R. Terebene, |j ; 

Water, ,^viij. — M. 

For pruritus and urticaria. 

43. R. Salicylic acid, ^ij ; 

Borax, gj • 

Glycerin, q. s. for 3J. — M. 

Mix the acid and borax with ^iv of gly- 
cerin. Heat gently until dissolved : then 
add glycerin to make ^j. This can be di- 
luted with glycerin, alcohol, or water to 
any extent. 

^j of the first mixture, .^j alcohol, and 
water to ^viij make a good proportion for 
pruritus and urticaria. 

44. R. Menthol, gr. ij ; 

Water, §j.— - M. 

For same. 



45. R. Subacetate of lead, 

Water, 
For same. 

46. R. Benzoic acid, 

Water, 
For same. 



Ml ; 
5viij.— M. 



p; 

Sviij.— M. 



Pastes. 

Unna's Gelatin Paste. 
47. R. Oxide of zinc, 

Glycerin, ^iij ; 

Gelatin, da. £i^s : 

Distilled water, 5jiv. — M. 



978 



LOCAL DISEASES. 



To this, as a base, 5 to 10 gr. of an anti- 
septic, as salicylic acid, resorcin, aristol, or 
ichthyol, or the chemical equivalent of the 
latter — namely, thiol — may be added. At 
the ordinary temperature it is elastic like 
rubber, and must be melted by sufficient 
heat before its application. When applied 
it should be dabbed with a light layer of 
wool to prevent adhesion to the clothes. 

This is known as Unna's paste, and is 
much used in subacute and chronic eczema 
and whenever the discharge is slight or 
absent. It is not adapted for parts covered 
with hair or for use in hot weather unless 
it be covered by the light wool mentioned 
above. 
48. Lassar 1 s is another paste largely used. 

It has the following composition : 
R. Zinc oxide and pow- 
dered starch, ad. ,^ij ; 
Vaselin, Jss ; 

Salicylic acid, gr. x. — M. 

Used for eczemas and other inflamma- 
tions, whether moist or dry, if the dis- 
charge be moderate. It should be spread 
thickly on, and be covered with cheese- 
cloth. If the inflammation be acute, it is 
better to leave out the salicylic acid for a 
time. 



For Animal Parasites. 

49. R. Ung. sulphuris, B. P. 

For the vegetable parasitic eruptions and 
scabies. 

50. Wilson's Formula : 

R. Sulphur, gss; 

Carbonate of potash, gj ; 

Benzoated lard, ^ijss ; 

Oil of chamomile, Tt\,xv. — M. 

51. Wilkinson's Formula: 

R. Sulphur, ^ 

Tar, V da. %j; 

Lard, J 

Precipitated chalk, ^ss ; 

Sulphide of ammo- 
nium, Ttlxv. — M. 
For tinea tonsurans and scabies. 
Kaposi recommends the following oint- 
ment: 

52. R. Naphthol, 15 parts ; 

Prepared chalk, 10 " 
Lard, 100 " 

Soft soap, 50 " — M. 

53. R. Iodide of sulphur, 

Iodide of potas- 
sium, da. gjss ; 
Water, Ixxx. — M. 



INDEX TO FORMULARY. 



Acne, Nos. 10, 11, 13, 38. 

Acne rosacea, 23, 30. 

Alopecia, 27, 28. 

Antiseptics, 32, 35, 36. 

Burns, 14, 48. 

Capillaries, dilatation of, 24. 

Chloasma, 7. 

Comedones, 11. 

Dermatitis, 15. 

Eczema, 8, 15, 16, 17, 18, 19, 20, 21, 22, 

26, 29, 31, 32, 34, 47, 48. 
Erythema, 26, 29, 33. 
Excoriations, 31, 32. 
Freckles, 5, 6, 7. 
Hyperemia, 1, 2, 3, 4, 29, 30. 



Hyperidrosis, Nos. 25. 

Impetigo contagiosa, 37. 

Lupus erythematosus, 23. 

Nsevus, 23. 

Parasiticides, 12, 49, 50, 51, 52, 53. 

Pityriasis versicolor, 7, 12. 

Pruritus, 16, 17, 18, 19, 20, 39, 40, 41, 42, 

43, 44, 45, 46. 
Psoriasis, 8, 9, 22. 
Scabies, 49, 50, 51, 52, 53. 
Seborrhea, 9, 25, 27, 28, 39, 40. 
Syphilis, 7. 
Tinea tonsurans, 51. 
Urticaria, 16, 39, 42, 43, 44, 45, 46. 
Wounds, 32. 



INDEX. 



Abnormalities in circulatory system, con- 
genital, 89 
Acrania, 81 

Adenoid vegetations, 700 
Alveola, 697 
Anaemia, simple or secondary, 507 

etiology, symptoms, diagnosis, 509 
treatment, 510 
Primary, 511 

etiology, morbid anatomy, 511 
symptoms, diagnosis, treatment, 512 
Lymphatic, 512 

etiology, morbid anatomy, 512 
symptoms, diagnosis, prognosis, treat- 
ment, 513 
Splenic, 513 

etiologv, morbid anatomy, svmptoms, 

513 
diagnosis, prognosis, treatment, 514 
Pernicious, 514 
Idiopathic, 514 

morbid anatomy, symptoms, etiology, 
treatment, 514 
Aneurysm of arteries, 923 
Angeioma, 482 
Animal heat in infancy, 75 
Ankle-joint, diseases of, 569 
Anus, absence of, imperforate, 488 
Appendicitis, 799 

etiology, anatomical character, 799, 800 
symptoms, 800-802 
diagnosis, 802 
prognosis, 803 
treatment, 804 
Arthritis, acute suppurative, 551 

treatment, 552 
Artificial feeding, 53-57 
Atelectasis, 861 
Acquired, 861 
symptoms, 862 
anatomical characters, 862 
treatment, 863, 864 
Atresia oris, 476 
Attitude of infant, 72 

B. 

Bathing of infant, 65 
Bladder, extroversion of, 489 
Bones, injuries of, 530 

long bones, 530, 531 

diagnosis, treatment, 531-533 

clavicle, 533 

humerus, 534 



Bones, injuries of, 

ulna, radius, epiphysis, femur, 535 
condyles, 537 
tibia* fibula, 538 
Inflammations of, 538 
etiology, 538 
periostitis, 539 

symptoms, 539, 540 
treatment, 540, 541 
chronic, 542 
syphilitic, 542 
epiphysitis, acute, 542 

causes, symptoms, treatment, 
542,543 
osteomyelitis, acute (diaphysitis), 543 
treatment, 548 
chronic diffuse, 548 

symptoms, progress, 548 
treatment, 549 
Tuberculosis of, 549 

diagnosis, prognosis, treatment, 550 
Arthritis, acute, suppurative, 551 
Bowleg, 496 

Brain, congestion of, 578 
causes, 578 
symptoms, 579 

anatomical characters, 580, 581 
Brain, incomplete, 83 
Burns, scalds, 829 
Bronchitis, 851 

causes, anatomical characters, 851-853 
symptoms, 854 
duration, 855 
diagnosis, prognosis, 856 
treatment, 857 

of mild bronchitis, 857 

of bronchitis affecting the tubes, 857, 

858 
internal, 859, 860 



C. 

Calculus in genito-urinary organs, 935 

urinary, 941 
Caput succedaneum, 99 
Caries, vertebral, 519 
prognosis 520 
treatment, 521 
. Spinal abscesses, 524 
Catarrh, intestinal, of infancy, 730 
etiology, 731 
age, dentition, 736 
symptoms, 736-739 

anatomical, 739 
diagnosis, prognosis, 743 

979 



980 



INDEX. 



Catarrhal laryngitis, 820 
Cephalhematoma, 100 
Cerebral hemorrhage, 584 
Cerebro-spinal fever, 421 
history, 421 
etiology, 423 
contagiousness, 424 
secondary, sex, age, 427, 428 
mode of commencement, 430 
nervous system, 431 
digestive system, 435 
•pulse, temperature, 437 
respiratory system, 438 
cutaneous surface, 438, 439 
urinary organs, 439 
special senses, 440 
symptoms of endemic, 441 
prognosis, diagnosis, 446, 447 
treatment, 448 
curative, 449 
internal, 452-455 
Cerebro-spinal system, disease of, 576 
Chicken-pox, 326 
Childhood, 17 

anatomy, physiology, 17, 18 
Cholera infantum, 743 

anatomical characters, 744 
diagnosis, prognosis, treatment, 747 
treatment medicinal, 749 
antiseptic, 749 

irrigation of stomach, 749, 750 
alkalies, astringents, 750 
stimulants, 750 
Chorea, ansemia, 653 
rheumatism, 653 
fright, irritation, 656 
intestinal irritation, 657 
lesions of brain, 657 
anatomical characters, 658 
symptoms, 659 
prognosis, course, 660 
diagnosis, 661 

treatment, medicinal, 661, 662 
Circulatory system, abnormalities of, 89 
Circumcision, 944 
Clavicle, injuries of, 533 
Clothing of infants, 66 
Club-foot, hollow (pes cavus), 502 
Colitis, 752 
Colostrum, 32 
Condyles, fracture of, 537 
Congestion of the stomach, 719 
Conjunctivitis of newly-born, 102 

mild or catarrhal, 103 
Constipation, 754 

symptomatic, causes, 754 
idiopathic, causes, 756 
treatment, 760 

hygienic measures, 761 
therapeutic measures, 762 
of newly-born, 130 

symptoms, treatment, 131, 132 
Coryza, anatomical characters, 818 

symptoms, prognosis, treatment, 819 
Cow's milk, diseases communicated by, 
57 



Craniotabes, 170 
Cretinism, 469 
diagnosis, 471 
treatment, 473 
Croup, pseudo-membranous, or true croup, 
831 
etiology, 831, 832 
anatomical characters, 833, 834 
symptoms, diagnosis, 834, 835 
prognosis, 836 

treatment, preventive, 837, 838 
surgical, 838, 839 
Cryptorchia, 935 
Curvatures, lateral, of spine, 525 
Cyanosis, 89-99 



D. 

Dactylitis, strumous, 190 

syphilitica, 237 
Deformities, 476 
Dentigerous cysts, 697 
Dentition, 691 

pathological results of, 691 
diagnosis, 693 
treatment, 694 
Second, 695 
Eanula, 696 

Tonsils, abscesses of, 698 
Chronic inflammation of tonsils, 698 

symptoms, 698 
Tonsillitis, recurrent, 699 

treatment, 700 
Adenoid vegetations, 700 
treatment, 701 
Diaphysitis, 543 

Diarrhoea of the newly-born, 128 
simple, 726 
causes, 726 

symptoms, anatomical characters, 727 
prognosis, treatment, 728 
choleriform, 743 
Digestive apparatus, diseases of, 680 

Stomatitis, simple or catarrhal 
680 
ulcerous, 681 
aphthous, 683 
Gangrene of the mouth, 684 
Dentition, 691 
alveola, 697 
Dilatation of stomach, 723 
Diarrhoea, 726 
system in infancy, 78 
Digits, supernumerarv, 490 
Union of, 491 

Flexion of phalangeal joints, 492 
Dilatation of the stomach, 723 
Diphtheria, 328 
etiologv, 331 

Klebs-Loeffier bacillus, 832 
pseudo-diphtheria, 333 
mixed infection, 334 
age, 334-345 
incubative period, 336 
modes of propagation, 337 
contracted from animals, 338 



INDEX. 



981 



Diphtheria, diagnosis, 340 

anatomical characters, 342 
blood, brain and spinal cord, 344 
tonsils, lungs, 345 
lymphatic glands, heart, 346 
mouth, stomach, intestines, 347 
spleen, liver, kidneys, 347 
symptoms, 348 
temperature, 349 
nares and eye, 350 
ear, 351 
albuminuria, 351 
paralysis, 354 
clinical history, 355 
time of commencement, 356 
loss of tendon-refiexes, 357 
palatal paralysis, 357, 358 
multiple paralysis, 359 
cardiac paralysis, 359-363 

its cause, 363 
prognosis, 365 
treatment, preventive, 366 
hygienic, 368 
stimulants, quinia, 370 
tinctura ferri chloridi, 371 
potassium chlorate, 372 
hvdrargvri chloridum corrosivum, 

"373 
hvdrargyri perchloridum (Br. 

"Phar.), 373 
calomel, 374 
trypsin, papoid, 374 
peroxyde of hydrogen, 375 
Diseases, local, of newly-born, 101 

Hsematoma of the sterno-cleido- 

mastoid muscle, 101 
Mastitis, 102 
Conjunctivitis, 102 

mild or catarrhal, 103 
Ophthalmia neonatorum, puru- 
lent, 103 
Gonorrheal, 103-108 
Umbilical vegetations, 108 

hemorrhage, 109 
Icterus, 112 

Septicemia of new-born, 115 
first group, 115-119 
second group, 119-122 
third group, 122, 123 
Thrush, 123 
Dysuria, 935 

E. 

Eclampsia, 614 

causes, 615 

premonitory stage, symptoms, 616 

partial, 617 

anatomical characters, 618 

diagnosis, prognosis, symptoms, 619 

treatment, 620 
Eczema, 956-967 
Elbow, disease of, 555 
Encephalocele, 83-85 
Endocarditis, 917 
Enteritis, 752 
Entero-colitis, 730 



Epilepsy, 622 

etiology, predisposing causes, 622 

age, exciting causes, 622 

mental emotion, traumatism, 623 

symptoms, 623 

attacks, minor and major, 624 

anatomical characters, 627 

pathology, 628 

diagnosis, 629 

prognosis, 630 

treatment, 630-634 
Epiphysis, injury of, 535 
Epiphysitis, acute, 542 
Erysipelas, 463 

age, point of commencement, 464 

causes, 465 

premonitory symptoms, 466 

symptoms, 466 

prognosis, duration, modes of death, 467 

pathological anatomy, prophylaxis, 
modes of treatment, 467-469 
Erythema, or rose-rash, 952 
Exercise of infant, 68, 69 



F. 

Feeding, infantile, 47 
over-feeding, 47 
insufficient, 48 
artificial, 53-57 
Feet, distortions of, 497 
Femur, injury of, 535 
treatment, 535-537 
Fever, scarlet, 250 
Intermittent, 399 
Remittent, 405 
Typhoid, 407 
Cerebro-spinal, 421 
Growing, 543 
Foot, amputation of, 575 

G. 

Gangrene of the mouth, 684 

anatomical characters, 684 
age, causes, 685 
symptoms, diagnosis, 686 
prognosis, treatment, 687, 688 
efflorescence, furring, and erup- 
tion upon tongue, 690 
Gastritis, 719 

cause, age, 720 

symptoms, anatomical characters, 721 
Follicular, 722 
Diphtheritic, 723 
Gastro-intestinal bacteria, 723 
Genito-urinary organs, diseases of, 927 
nerves in, 928 
etiology, 929 

prognosis, treatment, 931-935 
Calculi, dysuria, cryptorchia, 935 
Vulvitis, 936 
Preputial dilatation, 937 
Kidnev, abscess of (pvonephrosis), 

938" 
Perinephric abscess, 938 



982 



INDEX. 



Genitourinary organs, diseases of, 
^Nephrectomy, 940 
Urinary bladder, 940, 941 

calculi, 941, 942 
Urethra, wounds of, 942 
Penis, 944 
Scrotum, 947 
Testicles, tubercles of, 947 
sarcoma of, 947, 948 

German measles, 298 

Glottis, spasm of, 634 

Growing fever, 543 

Growth of infant, 26 



Hsematoma of sterno-cleido-mastoid mus- 
cle, 101 
Haemophilia, etiology, anatomical appear- 
ance, diagnosis, prognosis, treat- 
ment, 515 
Hare-lip, 476 
Heart, diseases of, 912 

position in childhood, 912 
functional disorders, diagnosis, prog- 
nosis, 912 
treatment, 912, 913 
Pericarditis, 913 
Myocarditis, 916 
Endocarditis, 917 
ulcerative, 919 
chronic, 920 
Hemorrhage, intracranial, 581 
cerebral, 584 
meningeal, 587 
Hernia of the abdomen, 809 
inguinal, 809, 810 
symptoms, 811 
femoral, 811 
umbilical, 811 

treatment, 812-814 
strangulated, 814 
umbilical, 817 
Hip-joint, diseases of, 558 
Hodgkin's disease, 512 
Human milk, 33 
Humerus, injuries of, 534 
Hydrencephalocele, 83-85 
Hydrocephalus, congenital, 589 
anatomical characters, 589 
etiology, symptoms, 592 
diagnosis, prognosis, 593 
treatment, 594 
acquired, 595 

causes, anatomical characters, 595 
symptoms, treatment, 596 
spurious, 611 

anatomical characters, symptoms, 612 
diagnosis, prognosis, 613 
treatment, 614 



Icterus neonatorum, 112 

treatment, 115 
Impetigo contagiosa, 967 



Incubator, the, 76, 77 
Indigestion, 714 
symptoms, 715 
prognosis, diagnosis, 716 
treatment, 717 
Infancy, attitude, movements, voice, 72 
Respiratory system in health, 73 

in disease, 73, 74 
Circulatory system, 74 
Pulse in health, 74 

in disease, 75 
Animal heat, 75 
Digestive system in, 78 
Nervous system in, 79 
Therapeutics in, 80, 81 
Infant, care of, bathing, 65 
clothing, sleep, 6Q, 67 
exercise, 68, 69 
Infantile feeding, 47 
diseases, diagnosis, 70 

general observations, features, 70, 71 
appearance of head, trunk, limbs, 71 
Intestinal catarrh of infancy, 730 
Intermittent fever, 399 
etiology, 400 
symptoms, 402 
treatment, 404 
Intracranial hemorrhage, causes, 581 

anatomical characters, 582 
Intubation, 839 

indications for, method of operating, 842 
difficulties of operator, 844 
accidents and dangers of, 845 
asphyxia, 846 
extraction, 846 
time of removal of tube, 846 
management after intubation, 847, 848 
Intussusception, 779 

without symptoms, 779, 780 
with symptoms, 780 

previous health, causes, 780 
seat, pathological anatomy, 781 
in small intestines, 784 
in large intestines, 782 
symptoms, 787 
diagnosis, 788 
duration, prognosis, 789 

J. 

Joints, diseases of, 552 

Synovitis, acute, serous, 552 
treatment, 552 
suppurative, 553 
Tubercular affections of, 553 
cause, diagnosis, 553 
prognosis, treatment, 554 
Shoulder-joint, inflammation, 554 
simple, acute, treatment, 554 
tubercular, treatment, 554, 555 
Elbow-joint, 555 
Wrist-joint, 556 

tubercular form, 556 
treatment, 557 
Hip-joint, synovitis, simple and acute, 
treatment, 558 



IXDEX. 



983 



Joints, diseases of, 

Hip-joint, tubercular, 558, 559 

symptoms, diagnosis, treatment, 
559-567 
Knee-joint, 567 
synovitis, acute, 567 

chronic, treatment, 567 
tubercular disease of, 568 

progress, symptoms, prognosis, 568 
treatment, 568, 569 
Ankle-joint, synovitis of, 569 
treatment, 569, 570 
tubercular disease of, 570 
treatment, 570-573 
Tarsus, 
synovitis of tarsal joints, treatment, 

573 
tubercular disease of tarsal joints, 
573 
symptoms, treatment, 573-575 

K. 

Keratitis, 

Herpetic or phlyctenular, 198 
duration, prognosis, 199 
treatment, 200 
Parenchymatous or diffuse, 201 
treatment, 201, 202 
Kidney, abscess of, 938 
tuberculosis of, 939 
tumors of, 939 
Knee-joint, diseases of, 567 
Knock-knee, 492 

L. 

Lactation of infant, 27 

rules in regard to, 38-42 
Laryngismus stridulus, 179, 634 
causes, 635 

anatomical characters, 636 
symptoms, 636 
diagnosis, prognosis, modes of death, 

637 
treatment, 638 
Laryngitis, catarrhal, 820 
Acute, 820 

symptoms, 821 
Chronic, 822 

anatomical characters, 822 
treatment, 822 
Spasmodic, 822 
causes, symptoms, 823 
anatomical characters, pathology, 

824 
diagnosis, 824 
prognosis, treatment, 825 
Laryngotomy, 828 

thyrotomy, burns and scalds, 829 
Larynx, diseases of, 828 
Leukaemia (leucocythsemia), 511 
Lockjaw, 132 



M. 



Malformations, 82 
Acrania, 82, 83 



Malformations, 

Incomplete brain, 83 

Meningocele, encephalocele, hydren- 

cephalocele, 83-85 
Spina bifida, 86-88 
Congenital abnormalities in circulatory 

system, 89 
Cyanosis, 89-99 
Caput succedaneum, 99 
Atresia oris, microstoma, 476 
Macrostoma, 476 
Hare-lip, 476, 477 
fissure partial, 477 
single, 478 
double, 479 
Hypertrophy of mucous glands and of 

lips, 480 
Tongue-tie, hypertrophy of tongue, 481 
Angeioma, papillomata, 482 
Palate, congenital defects of, 482 
. Staphylorraphy, 483 
Urinoplasty, 485 
Contracted soft palate, 486 
Rectum, imperforate, absence of, 487 
Anus, contraction of, 487 

imperforate, absence of, 488 
Bladder, extroversion of, 489 
Digits, supernumerary, 490 

union of, flexion of phalangeal joints, 
491, 492 
Knock -knee (genu valgum), 492 

treatment, 493 
Out-knee (genu extrorsum), 495 

treatment, 495 
Bowleg, 496 
Feet, distortions of, 497 
talipes calcaneus, 499 
varus, 500 
valgus, 501 
hollow, club (pes cavus), 502 
hypertrophy of toes and foot, 503 
Mastitis, 102 
Measles, etiology of, 242 
symptoms, 242-244 
complications, 245, 246 
anatomical characters, nature, 247 
diagnosis, prognosis, 247, 248 
treatment, 248, 249 
Measles, German, 298 
Mela?na neonatorum, 504 
age, etiology, 504-506 
diagnosis, prognosis, treatment, 507 
Meningitis, tubercular and non-tubercular, 
596 
age, pathological anatomy, 598 
causes, 601 

premonitory stage, 602 
symptoms, 603 
diagnosis, prognosis, 607, 608 
treatment, 609 
Meningocele, 83-85 
Milk, human, 33 

modified by diet, 34 

by retention in breast, 34 

by age and mental impressions, 35 

by the catamenial function, 36 



984 



INDEX. 



Milk, human, modified by pregnancy, and 
other causes, 36 
effect of medicine on, 37 
differences in quantity and quality, 

38 
rules in regard to lactation, 38-42 
Milk, cow's, diseases communicated by, 57 
Mortality of early life, 22 
causes, 24, 25 
prevention, 26 
Mother, in pregnancy, care of, 19 
Movements of infant, 72 
Mumps, 395 

etiology, incubation, 395 
symptoms, anatomical characters, 396 
complications, sequelae, 396, 397 
diagnosis, prognosis, treatment, 397, 398 
Myocarditis, 916 

cause, symptoms, 916 
diagnosis, treatment, 917 
Myxcedema, 469 

N. 

Nsevus, 924 

diagnosis, treatment, 924-926 
Necrosis, 545 
Nephrectomy, 940 

lumbar, 940 

abdominal, 940 
Nephritis in scarlet fever, 275, 276 
Nervous system in infancy, 79 
Nose, imperforate, 827 

hemorrhage of, 827 

foreign bodies in, 827, 828 



o. 

(Edema neonatorum, 150 
(Esophagus, 711 
Stricture of, 711 
Oesophagitis, 712 

anatomical characters, symptoms, 
treatment, 713 
Oi'dium albicans, 123 
Ophthalmia neonatorum, 103-108 
prognosis, 105 
prevention, 106 
treatment, 107, 108 
preventive treatment, 107 
Purulent neonatorum, gonorrhoea^ 103 
Strumous, 198 

Herpetic or phlyctenular keratitis, 198 
duration, prognosis, 199 
treatment, 200 
Parenchymatous or diffuse keratitis, 201 
treatment, 201, 202 
Osteomyelitis, acute, 543 
Necrosis, 545 

of entire diaphysis, 546 
Chronic circumscribed, 547 

treatment, 548 
Chronic diffuse, 548 
symptoms, progress, treatment, 548, 
549 
Osteoparesis imperfecta, 153 



Palate, congenital defects of, 482 
Papillomata, 482 
Paralysis in young children, 664 
facial, 671 

causes, symptoms, prognosis, 671 
treatment, 672 
pseudo-hypertrophic, 672 
anatomical characters, 674 
causes, prognosis, treatment, 675 
Rachitic, 180 
in diphtheria, 363 
Paraphimosis, 945 
Parasites of the skin, 971 
Parotitis, parotiditis, 395 
Pemphigus neonatorum, 151 
simplex, 151 
cachecticus, 152 
anatomy, 152 
treatment, 153 
Penis, 944 
Pericarditis, 913 
pathology, 913 
symptoms, diagnosis, 914 
prognosis, treatment, 915 
Perinephric abscess, 938 
Periostitis, 539 
Peripharyngeal abscess, 704 

anatomical characters, symptoms, 705 
diagnosis, prognosis, 707 
swallowing foreign substances, 708 
Peritonitis, 805 
etiology, 805, 806 
symptoms, 807 
diagnosis, prognosis, 808 
treatment, 808, 809 
Pertussis, 381 

incubative period, 381 
age, cause, 382 
pathological anatomy, 383 
symptoms, 383 

first and second periods, 384 
third period, 385 
complications, 385-388 
diagnosis, prognosis, 389 
treatment, 390 

carbolic acid, cocaine, 390, 391 
antipvrine, quinine, 391, 392 
sulphur, 393 
of complications, 394 
prophylaxis, 395 
Pharyngitis catarrhal, anatomical cha- 
racters, 701 
causes, symptoms, prognosis, 702 
diagnosis, treatment, 703 
Phimosis, 944 
Pleurisy, 876 

frequency, 876, 877 ; causes, 878-882 
anatomical characters, 882 
Plastic, 883 
Sero-fibrinous, 884 
Purulent, 884, 885 
Hemorrhagic, 885-888 
symptoms, 889 
physical signs, 891 



INDEX. 



985 



Pleurisy, hemorrhagic, 

palpitation, percussion, 891, 892 
auscultation. 892-894 
diagnosis, 894 
prognosis, S9o. 896 
treatment, 897 
internal remedies, 898 
Second stage, 899 
Thoracentesis, 901 

indications for, 901, 902 
mode of operating, 903 
for empyema, 904 
admission of air into pleural cavity, 905 
injury by instruments, 906 
washing out cavity, 906-908 
use of tent and tube in empyema, 908 
Paracentesis thoracis, 908-911 
Excision of the rib, 911 
Pneumonia, 864 
Catarrhal, 864 
etiology, 864 
anatomical 
Croupous, 867 
etiology, 867 

anatomical characters, 868 
Septic or embolismal, 869 
cheesy degeneration, 870 
symptoms, 870, 871 
physical signs, 872 
diagnosis, 873 
prognosis, 874 
treatment, 874 

of catarrhal pneumonia, 874 
of croupous pneumonia, 874, 875 
local, 875, 876 
Poliomyelitis acuta anterior, 664 
symptoms, 664 
progress, etiology, 666 
diagnosis, prognosis, 669 
treatment, 670 
Pott's disease, 519 
Preputial dilatation, 937, 938 
Prurigo, 954, 955 
Pulse of infant, 26 
in health, 74 
in disease, 75 
Purpura, 515 

etiology, anatomical appearances, 515 
symptoms, diagnosis, prognosis, treat- 
ment, 516 
Pyonephrosis, 938 

R. 

Kachitis, 156 
frequency, 156 
diagnosis, 158 
age of occurrence, 159 
etiology, 159 
inheritance, 159 

an ti hygienic conditions, food, 160 
pathology, 161 

changes in soft tissues (mucous mem- 
branes, ligaments, spleen, liver), 
abdominal protuberance, kidneys, 
urine, brain, spinal cord, 162, 163 



Rachitis, changes in osseous system in 
health, 163-165 
anatomical characters : 

1, in the stage of proliferation and 

altered nutrition, 165 

2, of the rachitic child, 169 
changes in cranial bones, 169 
craniotabes, 170 

changes in the vertebrae, 171 
in maxilla? and ribs, 172 
in bones of upper extremities and 

pelvis, 174 
in bones of lower extremities, 175 

effect on dentition, 176 

3, of stage of reconstruction, 176 
symptoms, 177 

laryngismus stridulus in, 179 
rachitic paralysis, 180 
acute rickets, 180 

treatment, hygiene, 181 
medicinal, 183-185 
Radius, fracture of, 535 
Ranula, 696 

Rectum, absence of, imperforate, 487 
Remittent fever, 405 

symptoms, diagnosis, treatment, 406 
Respiration of infant, 26 
Respiratory system in infants, 72 
Rheumatism, acute, 455 
causes, 456 
symptoms, 457 
pathology, 459 
duration, prognosis, 460 
diagnosis, treatment, 461-463 
Rotheln, 298 

premonitory stage, 300 
symptoms, tegumentary system, 300, 301 
mucous membrane, 301 
respiratory and digestive system, 302 
pulse, temperature, 302 
complications, prognosis, 303 
nature, incubative period, 303 
contagiousness, 303-305 
complications, diagnosis, prognosis ; treat- 
ment, 306 
Rubeola (see Measles). 

S. 

Scalds and burns, 829 
Scarlet fever, 250 

etiology, 250-252 

incubative period, 252, 253 

contagiousness, 254 

variations in type, 254-257 

age, 258 

clinical facts, 259 

symptoms, ordinary form, 260-263 

grave form, 264, 265 

irregular form, 265, 266 
complications and sequela?, 266-270 

coryza, 270 

inflammation of middle ear, 270 

scarlatinous rheumatism, 272 

pleuritis, 273 

dilatation of the heart, 273 



986 



INDEX. 



Scarlet fever, complications, etc. : 

nephritis, parenchymatous, 275 
interstitial, 276 
anatomical characters, 278 
diagnosis, 279 
prognosis, 281 
treatment, 283 

prophylaxis (care of patient, in- 
fected articles), 283-285 
hygienic, 285 
therapeutic, in mild cases, 286 

in severe cases, 287-289 
of complications and sequelae, 289- 
298 
Sclerema neonatorum, 149 
Scorbutus, etiology, 516 

morbid anatomy, symptoms, diagnosis, 
prognosis, treatment, 517, 518 
Scrofula, 186 
causes, 187 

anatomical characters, 188 
symptoms, 191 
prognosis, 193 
treatment, prophylactic, 193 

curative, 194 
strumous, dactylitic, 190 
Scrotum, 947 

Hydrocele, variocele, 947 
Scurvy (see Scorbutus). 
Septicaemia of the new-born, 115 
first group, 115-119 
second group, 119-122 
third group, 122, 123 
Shoulder, diseases of, 554 
Skin, diseases of, 949 

Erythema, or rose-rash, 950 
diagnosis, treatment, 951 
duration, pathology, 952 
Urticaria, varieties, 952 
papulosa, 953 
etiology, pathology, 953 
diagnosis, prognosis, treatment, 954 
Prurigo, 954 

symptoms, etiology, 954, 955 
pathology, diagnosis, prognosis, 
treatment, 955 
Eczema, 956 

vesiculosum, squamosum, rubrum, 

956 
pustulosum, impetiginodes, papillo- 
sum, erythematosus, 957 
age, 957 
etiology, pathology, anatomy, 958- 

962 " 
diagnosis, prognosis, treatment, 962, 

963 
treatment, local, 963-965 
of the head, 965, 966 
of the ears, face, evelids, lips, 

palms, 966 
of the nails, genitalia, 967 
Microbes, pathogenic effects of, 967 
Impetigo contagiosa, 967 

etiology, pathology, 967 
diagnosis, prognosis, treatment, 



Skin, diseases of, 

Seborrhoea, seborrhoea sicca, 968 
furfuracea universalis of the scalp, 

969 
prognosis, treatment, 970 
Parasites of the skin, 971 

scabies or the itch, diagnosis, 972 

treatment, 973 
pediculosis, 974 
Skull, injuries of, 530 

depression of, diagnosis, treatment, 
fractures, 530 
Sleep of infant, 67 
Spina bifida, 86 

Spinal cord and coverings, diseases of, 676 
membranes, congestion of, 677 
anatomical characters, 677 
symptoms, treatment, 678 
Spine, lateral curvature of, 525 
diagnosis, 526 
treatment, 527 
Staphylorraphy, 483 
St. Guy's dance, 650 
Stomach, 719 

congestion of, 719 
Stomatitis, 680 

simple or catarrhal, 680 

symptoms, appearance, treatment, 681 
ulcerous, 681 

causes, symptoms, prognosis, treatment, 
682 
aphthous, 683 

causes, symptoms, diagnosis, 683 
prognosis, treatment, 684 
Strumous ophthalmia, 198 
St. Yitus's dance, 650 
Synovitis, acute, serous, 552 

suppurative, 553 
Syphilis, etiology, 230 
"clinical history, 232-235 
visceral lesions, 235 
osseous lesions, 236 
prognosis, 238 
treatment, 238-241 



T. 

Tarsus, synovitis of, treatment, 573 
Temperature of infant, 26 
Testicles, tubercles of, 947 

sarcoma of, 947, 948 
Tetanus neonatorum, 132 

time of commencement, fatal cases, 135 
favorable cases, 136 

period of commencement, 136 
symptoms, 141 
mode of death, 142 
prognosis, 142 
duration in fatal cases, 143 

in favorable cases, 143 
diagnosis, preventive treatment, 143, 

144 
treatment, 145-149 
Tetany, 640 
causes, 640 
symptoms, 644 



INDEX. 



987 



Tetany, pathology, 64S 
diagnosis, prognosis, 649 
treatment, 650 
Therapeutics of infancy, 80, SI 
Thoracentesis, 901 
Thrush, 123 

causes, anatomical characters, 124, 125 
symptoms, 126 

diagnosis, prognosis, treatment, 127, 128 
Thvrotomy, 829 
Tibia, fracture of, 538 
Tongue, tongue-tie, hypertrophy of, 481 
Tonsil, abscess of, 698 

chronic inflammation of, 698 
Tonsillitis, recurrent, 699 
Tracheotomy, 848-850 
Tubercular affections of joints, 553 
Tuberculosis, 202 
etiology, 202-205 

anatomical characters of the tubercle, 
205 
in infancy and childhood, 207 
lungs, 208-211 
abdominal viscera, 211-214 
encephalon, 214-216 
bronchial glands, 216 
physical signs, 217-219 
diagnosis, 219-222 
prophylaxis, 222, 223 
treatment, 224 
high altitude, 224 
benefit of evergreen forest and use of 

turpentine, 225, 226 
creosote, 226-228 
guaiacol, 228 
tuberculin, 229 
of bone, 549 

diagnosis, prognosis, treatment, 550 
Typhoid fever, 407 

causation, 407—410 

anatomical characters, 410 

pathology, 411 

incubative period, symptoms, 412 

duration, 413 

relapses, second attacks, 414 

complications, 414, 415 

diagnosis, 415, 416 

prognosis, 416 

treatment, 416-420 

U. 

Ulna, injury of, 535 
Umbilical hemorrhage, 109 

etiology, prognosis, treatment, 111 
Vegetations, 108 
progress, treatment, 109 
Uranoplasty, 485 



Urethra, 942 
wounds of, 943 
foreign bodies in, 943 
calculus of, 943, 944 
imperforate, 944 

Urticaria, varieties, 952 



V. 



Vaccinia, 316 

appearances, symptoms, 319 

anomalies, complications, sequela?, 320 

vaccination, subsequent, 322 
protection from, 323 

virus, selection of, 324-326 
Varicella, 326 

symptoms, 326, 327 

complications, sequelae, 327 

diagnosis, prognosis, treatment, 327, 328 
Variola, 306 

etiology, incubative period, stage of in- 
vasion, 307 

stage of eruption, 308 

of desiccation and desquamation, 309 
Varioloid, 310 

mode of death, 310, 311 

anatomical characters, 311, 312 

prognosis, diagnosis, 312 

treatment, 314-316 
Vascular growths, 694 
Vertebral caries, 519 
Vessels, diseases of, 923 
Voice in infant, 72 
Vulvitis, 936 

etiology, 936, 937 

treatment, 937 

w. 

Weaning, 46, 47 
Weight of infant, 26 
Wet-nurse, selection of, 42-45 
Wet-nursing, 28 

its advantages and hindrances, 28 
physical conditions, if improper, 29-31 
course, 45, 46 
Whooping cough, 381 
Worms, intestinal, 765 

Ascaris lumbricoides, 765 
symptoms, 772 
diagnosis, prognosis, 774 
treatment, 775 
Oxyurus vermicularis, 767 
Tape-worm, Taenia solium, 768 
Taenia saginata, 769 

elliptica, or cucumerina, 770 
Bothriocephalus latus, 770 
Trichocephalus dispar, 770 
Wrist-joint, diseases of, 556 



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the memory of those who may find in the exigencies of practice the necessity of recalling 
the details of the dissecting room. Combining as it does a complete Atlas of Anatomy 
with a thorough treatise on systematic, descriptive and applied Anatomy, the work covers 
a more extended range of subjerts than is customary in the ordinary text-books. It not 
only answers every need of the student in laying the groundwork of a thorough medical 
education, but owing to its application of anatomical details to the practice of medicine 
and surgery, it also furnishes an admirable work of reference for the active practitioner. 



We always had a kindly regard for the illustra- 
tions in Gray, where each organ, tissue, artery, and 
nerve bear their respective names, and in this edi- 
tion color has been worked to advantage in bring- 
ingout the relationship of vessel and nerve. Of late 
years, many works on anatomy have been intro- 
duced to the profession, bat as a reference book for 
the practical everyday physician, and as a text-book 
for the student, we think it will be difficult to sup- 
plant Gray. — Buffalo Med. and Surg. Journal. 

It has thoroughly and completely established 
itself as the anatomy, par excellence.— Brooklyn 
Medical Journal. 

It embraces the whole of human anatomy, and 
it particularly dwells on the practical or applied 
part of the subject, so that it forms a most useful, 
intelligible and practical treatise for the student 
and general practitioner.— Dublin Journal of Medi- 
cal Science \ 

In modern times no book on any medical sub- 
ject has held the position of a standard so long as 
Gray's Anatomy. For logical arrangement, clear, 
terse, pointed, and yet full description, it is the 
peer of any work on any scientific subject. A 
pioneer in "helpful drawings, it is still in the van 
and leads in every improvement. The physician or 
student who requires but one work on anatomy 
will not need to ask which, nor will those who will 



have more than one need to ask which one to add. 
The work is admitted to be easily first on anatomy 
in any language. — TheAmer. Practitioner and News. 

Teachers of anatomy are almost unanimous in 
recommending "Gray" as the standard work for 
the student. The illustrations are conceded to be 
the best that have jet been given to the profes- 
sion. In short, Gray\f Ana'owy is the ideal text- 
book on this subject — Cleveland Med. Gazette. 

Gray's has been the unvarying standard for 
anatomical study by the vast majority of English- 
speaking medical "students for so long that it 
would seem an anomaly to see a student acquire 
such knowledge from some other source. — Medi- 
cal Fortnightly. 

The matchless book of the doctor's or surgeon's 
library is and has been Gray's Anatomy. Since 
1857 it has held the leadirg place in all colleges as 
a text-book and has bren the one central figure in 
the many text-books in anatomy that have claimed 
attention. It is still the standard text-bock.— The 
Kansas City Medical Index. 

The careful scrutiny to which it has been sub- 
jected in forty years, and the successive issues of 
thirteen editions have made it what it is to-day, 
the most perfect work of its kind extant.— Uni- 
versity Medical Magazine. 



HOBLYN'S DICTIONARY OF MEDICINE. A Dictionary of the Terms Used in Medicine and the 
Collateral Sciences. By Richard D. Hoblyn, M. D. In one large royal 12m o. volume of 520 double- 
columned pages. Cloth, $1.50; leather, §2.00. 



Lea Brothers & Co., Publishers, 706, 708 & 710 Sansom Street, Philadelphia. 



Anatomy, Physiology. 



HUMAN MONSTROSITIES 

BY BARTON C. HIRST, M.D., and GEORGE A. PIERSOL, M. D. 

Professor of Obstetrics in the University Professor of Anatomy and Embryology 

of Pennsylvania. in the University of Pennsylvania. 

Magnificent folio, containing 220 pages of text, illustrated with engravings, and 
39 fall page, photographic plates from nature. In four parts, price, each, $5, Limited 
edition, for sale by subscription only. Address the Publishers. 

We have before us the fourth and last part of 
the latest aud best work on human monstrosi- 
ties. This completes one of the masterpieces of 
American medical literature. Typographically 



and from an artistic standpoint, the work is uu- 



must slways retain the honor of being the first of 
its kind written in the English language. — The 
British Medical Journal. 

This work promises to be one for which a place 
must be found in th6 library of every anatomist, 



exceptionable. In this last and final volume pathologist, obstetrician and teratologic. Itisthe 
is presented the most complete bibliography of j joint production of an obstetrician, and an embry- 
teratologicalliterature extant. No library will be j oiogist, and his-tolcgist, and this fact makes it 
complete without this magnificent work.— Jour- certain that both the obstetric and anatomical 
nal of the American Medical Association. j sides of the subject will be fully represented and 

Altogether, Human Monstrosities is a satisfactory described. The book promises to be one of the 
production. It will take its place as a standard greatest value to the English-speaking medical 
work on teratology in medical libraries, and it | world.— Edinburgh Medical Journal. 



Allen's System of Human Anatomy. 

A System of Human Anatomy, Including Its Medical and Surgical 
Relations. For the use of Practitioners and Students of Medicine. By Harrison 
Allen, M. D,, Professor of Physiology in the University of Pennsylvania. With an 
Introductory Section on Histology by E, O. Shakespeare, M. D. ; Ophthalmologist to 
the Philadelphia Hospital. Comprising 813 double-columned quarto pages, with 380 
illustrations on 109 full page lithographic plates, many of which are in colors, and 241 
engravings in the text. In six Sections, each in a portfolio. Price per Section, $3.50 ; 
also bound in one volume, cloth, $23.00 ; very handsome half Eussia, raised bands and 
open back, $25.00. For sale by subscription only. Address the Publishers. 

Holden's Landmarks, Medical and Surgical. 

Landmarks, Medical and Surgical. By Luther Holden, F. E. C. S., 
Surgeon to St. Bartholomew's Hospital, London. Second American from the third and 
revised English ed., with additions by W. W. Keen, M. D., Professor of Artistic Anatomy 
in the Penna. Academy of Fine Arts. In one 12mo. volume of 148 pages. Cloth, $1.00. 

Clarke & Lockwood's Dissector's Manual 

The Dissector's Manual. By W. B. Clarke, F. E. C. S., and C. B. Lock- 
wood, F. E. C. S., Demonstrators of Anatomy at St. Bartholomew's Hospital Medical 
School, London. In one pocket-size 12mo. volume of 396 pages, with 49 illustrations. 
Limp cloth, red edges, $1.50. See Students' Series of Manuals, page 30. 

Messrs. Clarke and Loekwood have written a book | intimate association with students could have 
that can hardly be rivalled as a practical aid to the given. With such a guide as this, accompanied 
dissector. Their purpose, which is "how to de- ' by so attractive a commentary as Treves' Surgical 
scribe the best way to display the anatomical ! Applied Anatomy (same series), no student could 
structure," has been fully attained. They excel in i fail to be deeply and absorbingly interested in the 
a lucidity of demonstration and graphic terseness i study of anatomy.— New Orleans Medical and Sur^ 
of expression, which only a long" training and ■ gical Journal. 

Treves' Surgical Applied Anatomy. 

Surgical Applied Anatomy. By Frederick Treves, F. E. C. S., Senior 
Demonstrator of Anatomy and Assistant Surgeon at the London Hospital. In one pocket- 
size 12mo. volume of 540 pages, with 61 illustrations. Limp cloth, red edges, $2.00. See 
Students' Series of Manuals, p. 30. 

Bellamy's Surgical Anatomy. 

The Student's Guide to Surgical Anatomy : Being a Description of the 
most Important Surgical Begions of the Human Body, and intended as an Introduction to 
Operative Surgery. By Edward Bellamy, F. R. C. S., Senior Assistant- Surgeon to the 
Charing- Cross Hospital. In one 12mo. vol. of 300 pages, with 50 illus. Cloth, $2.25. 

Wilson's Human Anatomy. 

A System of Human Anatomy, General and Special. By Erasmus 
Wilson, F. E. S. Edited by W. H. Gobrecht, M. D., Professor of General and Surgical 
Anatomy in the Medical College of Ohio. In one large and handsome octavo volume 
of 616 pages, with 397 illustrations. Cloth, $4.00 ; leather, $5.00. 



HARTSHORNE'S handbook of anatomy 
AND PHYSIOLOGY. Second edition, revised. 
12mo., 310 pages, 220 woodcuts. Cloth, $1.75. 

HORNER'S SPECIAL ANATOMY AND HISTOL- 



OGY. Eighth edition. In two octavo volumes 
of 1007 raepi. with 320 woodcuts. Oloth. $fi.OO. 
CLELAND'S DIRECTORY FOR THE DISSEC- 
TION OF THE HUMAN BODY. 12mo., 178 pp. 
CI th, $1.25. 



Lea Brothers & Co., Publishers, 706, 708 & 710 Sanson) Street, Philadelphia. 



Physics, Physiology, Anatomy, Chemistry. 7 
Draper's Medical Physics. 

Medical Physics. A Text-book for Students and Practitioners of Medicine. 
Bv John C. Draper, M.D., LL. D., Prof, of Chemistry in the Univ. of the City of 
New York. In one octavo vol. of 734 pages, with 376 woodcuts, mostly original. Cloth, $4. 
No man in America was better fitted than Dr. I culties to be encountered in bringing his subject 
Draper for the task he undertook and he has pro- within the grasp of the average student, and that 
vided the student and practitioner of medicine i he has succeeded so well proves once more that 
with a volume at once readable and thorough. I the man to write for and examine students is the 
Even to the student who has some knowledge of ! one who has taught and is teaching them. The 
physics this book is useful, as it shows him its j book is well printed and fully illustrated, and in 
applications to the profession that he has chosen, every way deserves grateful recognition.— The 
Dr. Draper, as an old teacher, knew well the diffi- I Montreal Medical Journal. 

Reichert's Physiology.— Preparing. 

A Text-Book on Physiology. By Edward T. Reichert, M. D., Professor 
of Physiology in the University of Pennsylvania, Philadelphia. In one very handsome 
octavo volume of 800 pages, fully illustrated. 

Power's Human Physiology.— Second Edition. 

Human Physiology. By Henry Power, M. B., F. R. C. S., Examiner in 
Physiology, Royal College of Surgeons of England. Second edition. In one 12mo. vol. 
of 509 pp., with 68 illustrations. Cloth, $1.50. See Students 1 Series of Manuals, p. 30. 

Robertson's Physiological Physics. 

Physiological Physics. By J. McGregor Robertson, M. A., M. B., 
Muirhead Demonstrator of Physiology, University of Glasgow. In one 12mo. volume of 
537 pages, with 219 illus. Limp cloth, $2. See Students' Series of Manuals, page 30. 

The title of this work sufficiently explains the I ments. It will be found of great value to the 
nature of its contents. It is designed as a man- ! practitioner. It is a carefully prepared book of 
ua! for the student of medicine, an auxiliary to ! reference, concise and accurate, and as such we 
his text-book in physiology, and it would be particu- | heartily recommend it. — Journal of the American 
iarly useful as a guide to his laboratory experi- | Medical Association. 



Dalton on the Circulation of the Blood. 

Doctrines of the Circulation of the Blood. A History of Physio- 
logical Opinion and Discovery in regard to the Circulation of the Blood. By John C. 
D Alton : M. D., Professor Emeritus of Physiology in the College of Physicians and Sur- 
geons, New York. In one handsome l2mo. volume of 293 pages. Cloth, $2. 

Dr. Dalton's work is the fruit of the deep research I ation for those plodding workers of olden times, 
of a cultured mind, and to the busy practitioner it I who laid the foundation of the magnificent temple 
cannot fail to be a source of instruction. It will of medical science as it now stands. — New Orleans 
inspire him with a feeling of gratitude and admir- | Medical and Surgical Journal. 



Bell's Comparative Anatomy and Physiology. 

Comparative Anatomy and Physiology. ByF. Jeffrey Bell, M. A., 
Professor of Comparative Anatomy at King's College, London. In one 12mo. vol. of 561 
pages, with 229 illustrations. Limp cloth, $2. See Students' Series of Manuals, page 30, 

The manual is preeminently a student's book — I it the best work in existence in the English 
clear and simple in language and arrangement, language to place in the hands of the medical 
It is well and abundantly illustrated, and is read- student. — Bristol Medico- Chirurgical Journal. 
able and interesting. On the whole we consider | 

Ellis' Demonstrations of Anatomy.— Eiglith Edition. 

Demonstrations of Anatomy. Being a Guide to the Knowledge of the 
Human Body by Dissection. By George Viner Ellis, Emeritus Professor of Anatomy 
in University College, London. From the eighth and revised London edition. In one 
verj handsome octavo volume of 716 pages, with 249 illus. Cloth, $4.25 ; leather, $5.25. 

Roberts' Compend o! Anatomy. 

The Compend of Anatomy. For use in the dissecting-room and in pre- 
paring for examinations. By John B. Eoberts, A. M., M. D., Lecturer in Anatomy in 
the University of Pennsylvania. In one 16mo. vol. of 196 pages. Limp cloth, 75 cents. 



WOHLER'S OUTLINES OF ORGANIC CHEM- 
ISTRY. Edited by Fittig. Translated by Ika 
Remsen, M. D , Ph. D. In one 12mo. volume of 
550 pages. Cloth, $3. 

LEHM ANN'S MANUAL OF CHEMICAL PHYS- 
IOLOGY. In one octavo volume of 327 pages, 
with 41 illustrations. Cloth, $2.25. 



CARPENTER'S HUMAN PHYSIOLOGY. Edited 
by Henry Power. In one octavo volume.' 

CARPENTER'S PRIZE ESSAY ON THE USE AND 
Abuse of Alcoholic Liquors in Health and Dis- 
ease. With explanations of scientific words. Small 
12mo. 17S pages. Cloth, 60 cents. 



Lea Brothers & Co., Publishers, 706, 708 & 710 Sansom Street Philadelphia. 



8 



Physiology— (Continued), Chemistry. 



Foster's Physiology.— Sixth American Edition. Just Ready. 

Text-Book of Physiology. By Michael Foster, M. D., F. K. S., Prelec- 
tor in Physiology and Fellow of Trinity College, Cambridge, England. Sixth American 
edition, with notes and additions. In one handsome octavo volume of 922 pages, with 
257 illustrations. Cloth, $4.50; leather, $5.50. 
Notices of previous edition are appended. 
It is unquestionably the standard text book on I stowed upon it. Apparently nothing that is known 



physiology for students and practitioners. The 
moderate price of this well-issued book at once 
shows how popular the work has become. The 
style is plain enough even for the beginner; the 
details are sufficient for the teacher; and the 
manner of dealing with the topics is well-ar- 
ranged for the advantage of the practitioner. — 
Virginia Mediial Monthly. 

Foster's Physiology is an accepted text-book in 
almost every medical college in this country, and 
already commended to ail medical students. For 
the physician who aims to keep abreast of all that 
is new that is true in medicine, a work like this 
is a necessity. The illustrations are excellent and 
are well printed — The Cincinnati Lancet-CU- ic. 

One cannot read a single chapter without being 
impressed with the care that the author has be- 



up to the present year concerning vital processes 
has escaped his painstaking attention. The details 
receive the fullest consideration. The additions 
which have been made to this last edition are 
caused by an effort to explain more fully and at 
greater length what seemed to be the most funda- 
mental and important topics. The publishers 
have subjected it to the searching revision of one 
of the foremost American professors of physio- 
logy. We have nothing but words of the highest 
praise for the classical and thorough manner in 
which the work is written, as well as for the liber- 
ality of the publishers for selling such a large 
work, and one which must necessarily be very 
costly to produce, for an extremely moderate 
price. — The Canada Medical Record. 



Dalton's Physiology.— Seventh Edition. 

A Treatise on Human Physiology. Designed for the use of Students 
and Practitioners of Medicine. By John C. Dai/ton, M. D., Professor of Physiology in 
the College of Physicians and Surgeons, New York, etc. Seventh edition, thoroughly 
revised and rewritten. In one very handsome octavo volume of 722 pages, with 252 beau- 
tiful engravings on wood. Cloth, $5.00 ; leather, $6.00. 



From the first appearance of the book it has 
been a favorite, owing as well to the author's 
renown as an oral teacher as to the charm of 
simplicity with which, as a writer, he always 
succeeds in investing even intricate subjects 



have never been in any doubt as to its sterling 
worth. — iV T . Y. Medical Journal. 

Professor Dalton's well-known and deservedly- 
appreciated work has long passed the stage at 
which it could be reviewed in the ordinary sense. 



It must be gratifying to him to observe the fre- | The work is eminently one for the medical prac 
quency with which his work, written for students titioner, since it treats most fully of those branches 



and practitioners, is quoted by other writers on 
physiology. This fact attests its value, and, in 
great measure, its originality. It now needs no 
such seal of approbation, however, for the thou- 
sands who have studied it in its various editions 



of physiology which have a direct bearing on the 
diagnosis and treatment of disease. The work is 
one which we can highly recommend to all our 
readers. — Dublin Journal of Medical Science. 



Chapman's Human Physiology. 

A Treatise on Human Physiology. By Henry C. Chapman, M. I)., 
Professor of Institutes of Medicine in the Jefferson Medical College of Philadelphia. 
In one octavo volume of 925 pages, with 605 engravings. Cloth, $5.50 ; leather, $6.50. 



It represents very fully the existing state of 
physiology. The present work has a special value 
to the student and practitioner as devoted more 
to the practical application of well-known truths 
which the advance of science has given to the 
profession in this department, which may be con- 
sidered the foundation of rational medicine. — Buf- 
falo Medical and Surgical Journal. 

Matters which have a practical bearing on the 
practice of medicine are lucidly expressed; tech- 



nical matters are given in minute detail; elabo- 
rate directions are stated for the guidance of stu- 
dents in the laboratory. In every respect the 
work fulfils its promise, whether as a complete 
treatise for the student or for the physician ; for 
the former it is so complete that he need look no 
farther, and the latter will find entertainment and 
instruction in an admirable book of reference.— 
North Carolina Medical Journal. 



Schofield's Elementary Physiology. 

Elementary Physiology for Students. By Alfred T. Schofield, 
M. D., Late House Physician London Hospital. In one 12mo. volume of 380 pages, with 
227 engravings and 2 colored plates containing 30 figures. Cloth, $2.00. 



Frankland & Japp's Inorganic Chemistry. 

Inorganic Chemistry. By E. Frankeand, D. C. L., F. E. S., Professor of 
Chemistry in the Normal School of Science, London., and F. E. Japp, F. I. C, Assistant 
Professor of Chemistry in the Normal School of Science, London. In one handsome 
octavo volume of 677 pages with 51 woodcuts and 2 plates. Cloth, $3.75 ; leather, $4.75. 



Clowes' Qualitative Analysis.— Third Edition. 

An Elementary Treatise on Practical Chemistry and Qualitative 
Inorganic Analysis. Specially adapted for use in the Laboratories of Schools and 
Colleges and by Beginners. By Frank Clowes, D. Sc, London, Senior Science-Master 
at the High School, Newcastle-under Lyme, etc. Third American from the fourth and 
revised English edition. In one 12mo. vol. of 387 pages, with 55 illus. Cloth, $2.50. 



Lea Brothers & Co., Publishers, 706, 708 & 710 Sansom Street, Philadelphia. 



Chemistry — (Continued). 



Simon's Chemistry.— New (5th) Edition. Just Ready. 

Manual Of Chemistry. A Guide to Lectures and Laboratory work for Begin- 
ners in Chemistrv. A Text-book specially adapted for Students of Pharmacy and Medi- 
cine By W. Simon", Ph. D., M. D., Professor of Chemistry and Toxicology in the College 
of Physicians and Surgeons, Baltimore, and Professor of Chemistry in the Maryland Col- 
lege of Pharmacy. New (5th) edition. In one 8vo. vol. of 501 pp., with 44 woodcuts and 
8 colored plates illustrating 64 of the most important chemical tests. Cloth, $3.25. 



The exhaustion of the very large fourth edition 
in less than two years indicates the leading posi- 
tion achieved by'Professor Simon's Chemistry as a 
text-book in medical and pharmaceutical colleges. 
It furnishes an admirable selection of material 
bearing upon the laws and phenomena of chem- 



referred to this series of colorsand color changes. 
The new edition has been most carefully revised 
in accordance with the advance of science and in 
order to bring it into complete harmony with the 
new Pharmacopoeia. All chemicals mentioned in 
the last issue of that wcrk are included. Special 



istry. 'As an aid to laboratory work a number of i care has been taken to detail the most modern 

experiments have been added. Physicians as well methods for chemical examination in clinical 

as students will appreciate the value of the colored diagnosis. The author's experience as a physician 

plates of reactions, which give a permanent and and as a teacher of medical and pharmaceutical 

accurate series of standards for comparison of students is reflected in the special adaptation of 

tests, a matter not susceptible of satisfactory his book to the needs of all concerned with the 

explanation in words. In medical practice im- applications of chemistry to the' art of healing. — 

portant pathological and toxicological questions Southern Practitioner. 
depending on the test-tube may with certainty be 

Attfield's Chemistry.— New (14th) Edition. Just Ready. 

Chemistry, General, Medical and Pharmaceutical; Including the 

Chemistry of the U. S. Pharmacopoeia. A Manual of the General Principles of the 
Science, and their Application to Medicine and Pharmacy. By John Attfield, M. A., 
Ph.D., F. I.C., F. R. S., etc., Professor of Practical Chemistry to the Pharmaceutical 
Society of Great Britain, etc. Fourteenth edition, specially revised by the Author 
for America, to accord with the new U. S. Pharmacopoeia. In one 12mo. volume of 794 
pages, with 88 illustrations. Cloth, $2.75; leather, $3.25. 

This substantial and handsome treatise on those 
parts of chemical science, which are of special in- 
terest to the physician and the pharmacist, is 
adapted not only "to be a manual of instruction, but 
also a work of reference. It is replete with the 
latest information, and considers with more or less 
completeness the chemistry of every substance 
recognized officially or in general practice. The 
analytical tables are most excellent. Organic 
Chemistry receives attention in a most compre- 
hensive manner, as do practical toxicology and j copceia, of which it is a worthy companion. — The 
physiological chemistry". The concluding parts i Pittsburg Med ; cal Review. 



consist of a laboratory guide to physical and 
quantitative chemical analysis and of a large 
number of useful tables. The etymological notes, 
scattered through the book, are a very valuable 
feature, as are also the questions following each 
section. The eighty-eight illustrations leavenoth- 
ing to be desired. The metric system, and the 
modern scientific chemical nomenclature, have 
been entirely adopted, bringing the work into 
close touch with the latest United States Pharma- 



Fownes' Chemistry.— Twelfth Edition. 

A Manual of Elementary Chemistry; Theoretical and Practical. By 
George Fownes, Ph. D. Embodying Watts' Physical and Inorganic Chemistry. New 
American, from the twelfth English edition. In one large royal 12mo. volume of 1061 
pages, with 168 engravings and a colored plate. Cloth, $2.75 ; leather, $3.25. 



Fownes' Chemistry has been a standard text- 
book upon chemistry for many years. Its merits 
are very fully known by chemists and physicians 
everywhere in this country and in England. As 
the science has advanced by the making of new 
discoveries, the work has been revised so as to 
keep it abreast of the times. It has steadily 
maintained its position as a text-book with medi- 



cal students. In this work are treated fully: Heat, 
Light and Electricity, including Magnetism. The 
influence exerted by these forces in chemical 
action upon health and disease, etc., is of the most 
important kind, and should be familiar to every 
medical practitioner. We can commend the 
work as one of the very best text-books upon 
chemistry extant. — Cincinnati Med. News. 



Bloxam's Chemistry.— Fifth Edition. 

Chemistry, Inorganic and Organic. By Charles L. Bloxam, Professoi 
of Chemistry in King's College, London. .New American from the fifth London 
edition, thoroughly revised and much improved. In one very handsome octavo 



volume of 727 pages, with 292 illustrations. 

Comment from us on this standard work is al- 
most superfluous. It differs widely in scope and 
aim from that of Attfield, and in its way is equally 
beyond criticism. It adopts the most direct meth- 
ods in stating the principles, hypotheses and facts 
of the science. Its language is so terse and lucid, 
and its arrangement of matter so logical in se- 
quence that the student never has occasion to 



Cloth, $2.00 ; leather, $3.00. 
complain that chemistry is a hard study. Much 
attention is paid to experimental illustrations of 
chemical principles and phenomena, and the 
mode of conducting these experiments. The book 
maintains the position it has always held as one of 
the best manuals of general chemistry In the Eng- 
lish language. — Detroit Lancet. 



Luff's Manual of Chemistry. 

A Manual of Chemistry. For the use of students of medicine. By Arthur 
P. Luff, M. D., B. 8c, Lecturer on Medical Jurisprudence and Toxicological Chemistry, 
St. Mary's Hospital Medical School, London. In one 12mo. vol. of 522 pages, with 36 
engravings. Cloth, $2.00. See Students 1 Series of Manuals, page 30. 

Greene's Manual of Medical Chemistry. For the use of Students. By 
William H. Greene, M. D., Demonstrator of Chemistry in the University of Pennsyl- 
vania. In one 12mo. volume of 310 pages, with 74 illus. Cloth, $1.75. 

Lea Brothers & Co., Publishers, 706, 708 &710 Sansom Street, Philadelphia. 



10 Chemistry — (Continued), Pharmacy. 

Caspari's Pharmacy.— Just Ready. 

A Treatise on Pharmacy, for Students and Pharmacists. By 
Charles Caspari, Jr, Ph. G., Professor of the Theory and Practice of Piannacy in the 
Maryland College of Pharmacy, Joint Editor of The National Dispensatory, fifth edition. 
In one very handsome octavo volume of 678 pages, with 288 engravings. Cloth, §4.50. 

The author is widely known as joint editor of The National Dispensatory (see next page) 
and as Professor of Pharmacy in one of the foremost pharmaceutical colleges in America. 
He is therefore exceptionally qualified to prepare a work of the highest merit, both as a 
text-book for students, and as a practical reference for pharmacists m all the multifarious 
details of their operations. Modern in every particular, convenient in size through avoid- 
ance of obsolete and unnecessary matter, and richly illustrated, Caspari's Pharmacy is 
equally assured of immediate popularity with pharmacists and of adoption as the standard 
text-book for pharmaceutical students. 

Vaughan & No?y on Ptomains and Leucomains— New Ed. 

Ptomains, Leucomains, Toxines and Antitoxines. By Victor C. 
Vaughan. Ph. D., M. D., Professor of Physiological and Pathological Chemistry, and 
Associate Professor of Therapeutics and Materia Medica in the University of Michigan, 
and Frederick G. Novy, M. D., Instructor in Hygiene and Physiological Chemistry 
in the University of Michigan. New (third) edition. In one 12mo. volume of about 500 
pages. In press. 

A notice of the previous issue is appended. 
This book is one that is of the greatest import- 
ance, and the modern physician who accepts 
bacterial pathology cannot have a complete 
knowledge of this subject unless he has carefully 
perused it. To the toxicologist the subject is 
alike of great import, as well as to the hygienist 



and sanitarian. It contains information which 
is not easily obtained elsewhere, and which is 
of a kind that no medical thinker should be 
without. — The American Journal of the Medical 
Sciences. 



Remsen's Theoretical Chemistry.— Fourth Edition. 

Principles of Theoretical Chemistry, with special reference to the Con- 
stitution of Chemical Compounds. By Ira Bemsen, M. D., Ph. D., Professor of Chem- 
istry in the Johns Hopkins University, Baltimore. Fourth and thoroughly revised edi- 
tion. In one handsome royal 12mo. volume of 325 pages. Cloth, $2 00. 

The fourth edition of Professor Remsen's well- I lation into German and Italian speaks for its ex- 
known book comes again, enlarged and revised, alted position and the esteem in which it is held 
Each edition has enhanced its value. We may say j by the most prominent chemists. We claim for 
without hesitation that it is a standard work on this little work a leading place in the chemical 
the theory of chemistry, not excelled and scarcely literature of this country. — The American Journal 
equalled by any other in any language. Its trans- | of the Medical Sciences. 



Charles' Physiological and Pathological Chemistry. 

The Elements of Physiological and Pathological Chemistry. A 

Handbook for Medical Students and Practitioners. Containing a general account of 
Nutrition, Foods and Digestion, and the Chemistry of the Tissues, Organs, Secretions and 
Excretions of the Body in Health and in Disease. Together with the methods for pre- 
paring or separating their chief constituents, as also for their examination in detail, and 
an outline syllabus of a practical course of instruction for students. By T. Cranstoitn 
Charles, M. D., F. E. S.~ M. S., formerly Assistant Professor and Demonstrator of Chem- 
istry and Chemical Physics, Queen's College, Belfast. In one handsome octavo volume 
of 463 pages, with 38 woodcuts and 1 colored plate. Cloth, $3.50. 

Dr. Charles is fully impressed with the impor- | nowadays. Dr. Charles has devoted much space 
tance and practical reach of his subject, and he to the elucidation ot urinary mysteries. He does 
has treated it in a competent and instructive man- this with much detail, and yet in a practical and 
ner. We cannot recommend a better book than intelligible manner. In fact, the author has filled 
the present. In fact, it fills a gap in medical text- \ his book with many practical hints.— Medical Rec- 
books, and that is a thing which can rarely be said j ord. 

Hoffmann and Powers' Analysis. 

A Manual of Chemical Analysis, as applied to the Examination of Medi- 
cinal Chemicals and their Preparations. Being a Guide for the Determination of their 
Identity and Quality, and for the Detection of Impurities and Adulterations. For the 
use of Pharmacists, Physicians, Druggists and Manufacturing Chemists, and Pharmaceu- 
tical and Medical Students. By Frederick Hoffmann, A. M., Ph. D., Public Analyst to 
the State of New York, and Frederick B. Power, Ph. D., Professor of Analytical Chem- 
istry in the Philadelphia College of Pharmacy. Third edition, entirely rewritten and 
much enlarged. In one octavo volume of 621 pages, with 179 illustrations. Cloth, $4.25. 

Ralfe's Clinical Chemistry. 

Clinical Chemistry. By Charles H. Eaefe, M. D., F. E. C. P., Assistant 
Physician at the London Hospital. In one pocket-size 12mo. volume of 314 pages, 
with 16 illus. Limp cloth, red edges, $1.50. See Students' Series of Manuals, page 30. 

Lea Brothers & Co., Publishers, 706, 708 & 710 Sansom Street, Philadelphia. 



Pharmacy, flateria fledica, Therapeutics. 11 

NEW AND THOROUGHLY REVISED EDITION. 

The National Dispensatory. 

Containing the Natural History, Chemistry, Pharmacy, Actions and Uses of Medi- 
cines, including those recognized in the Pharmacopoeias of the United States, Great 
Britain and Germany, with numerous references to the French Codex. By Alfred 
Stille, M. D., LL. D , Profess rr Emeritus of the Theory and Practice of Medicine and of 
Clinical Medicine in the University of Pennsylvania, John M. Maisch, Phar. D., late 
Professor of Materia Medica and Botany in Philadelphia College of Pharmacy, Secretary 
to the American Pharmaceutical Association, Charles Caspari, Jr., Ph. G., Professor 
of Pharmacy in the Maryland College of Pharmacy, Baltimore, and Henry C. C. Maisch, 
Ph. G., Ph.' D. New (fifth) edition, thoroughly revised in accordance with the new U. S. 
Pharmacopoeia (Seventh Decennial Eevision). In one magnificent imperial octavo 
volume of 1910 pages, with 320 engravings. Cloth, $7.25 , leather, $8.00. With Ready 
Eeference Thumb letter Index, cloth, $7.75; leather, $8.50. 

ON the first appearance of The National Dispensatory fifteen years ago it was at once 
recognized by the pharmaceutical and medical professions as satisfying the need 
for a work affording all necessary information upon its subject, with authoritative 
accuracy, and with a completeness and convenience attainable only by the exclusion of 
obsolete matter. Its success in filling this want is fully attested by the rapid demand for 
five editions, and the opportunity thus afforded has been well used in successive revisions, 
each placing it abreast of the day and maintaining the characteristics which had won for 
it a leading position. 

Of all its issues the present embodies the results of the most exhaustive revision. 
The sweeping changes in the new United States Pharmacopoeia are thoroughly incorpor- 
ated, with official authorization of the Committee of Eevision, and full use has been made 
of all valuable material in the latest issues of foreign Pharmacopoeias. The volume is 
accordingly rich in pharmaceutical and chemical information, with data, formulas, tables, 
etc., gathered from all official sources, but this constitutes only a single department of its 
usefulness. As an encyclopaedia of the latest and best therapeutical knowledge it deals 
not only with all official drugs, but also with all the new synthetic remedies of value 
and with the unofficial prep irations now so largely in use. Pharmacists will appreciate 
its systematic descriptions of the materia medica, its clear explanations of chemical and 
pharmaceutical processes and tests, and its illustrations of important drugs and of the 
most improved apparatus. Physicians will readily perceive the indispensable assistance 
offered by its authoritative statements as to the efficacy of drugs in the light of the most 
recent medical advances. Arranged alphabetically in the text, this information is 
placed most suggestively at command by the recommendations grouped under the various 
Diseases in the Therapeutical Index. Together with the General Index this covers more 
than one hundred treble-columned pages containing 25,000 references. The immensity 
of detail comprised in this single volume of 1900 pages is thus most forcibly indicated. 
Though the present edition contains far more matter than its predecessor it is maintained 
at the same price in view of the ever- increasing demand. 'Weights and Measures are 
given in both Ordinary and Metric Systems. 

In brief the new edition of The National Dispensatory is presented to the medical 
and pharmaceutical professions as the equivalent of a whole library of pharmaceutical and 
therapeutic information ; it is the standard of accuracy, the embodiment of completeness 
without inconvenient bulk, and a marvel of cheapness owing to the widespread demand 
for it as the authority. 



The careful examination of this large volume 
will strike the reader with surprise at the great 
number of new articles added, and the amount of 
useful and accurate information regarding their 
properties, methods of preparation and therapeu- 
tical effects. The large number of new articles 
containing all the latest synthetic remedies and 
unofficial remedies, compass the entire range of 
available information in the line of the work. A 
number of very complete tables together with all 
the official re-agents and solutions for qualitative 
and quantitative tests, appear in the appendix. 
Altogether this work maintains its previous high 
reputation for accuracy, practical useiulness and 
encyclopaedic scope, and is indispensable alike to 
the pharmacist and physician. Every druggist 
knows of it and uses it, and almost every physi- 
cian properly consults it when desirous of settling 
all doubtful questions regarding the properties, 
preparation and uses of drugs. — Medical Record. 

The descriptions of materia medica are clear, 
thorough and systematic, as are also the explana- 
tions of chemical and pharmaceutical processes 
and tests. The therapeutical portion has been re- 



vised with equal care and the statements of the 
action and uses have been arranged not only 
alphabetically under the various drugs, but for 
practical medical usefulness have also been placed 
at the instant command of those seeking infor- 
mation in the treatment of special diseases by 
being arranged under the various diseases in a 
therapeutical index. The readiness with which 
any of the vast amount of information contained 
in this work is made available is indicated by the 
twenty-five thousand references in the two in- 
dexes at the end of the volume. — Boston Medical 
and Surgical Journal. 

It is the official guide for the medical and phar- 
maceutical professions. — Buffalo Medical and Sur- 
gical Journal. 

The book is recommended most highly as a 
book of reference for the physician and is invalu- 
able to the druggist in his every-day work. — The 
Therapeutic Gazette. 

This edition of the Dispensatory should^be recog- 
nized as a national standard. — The North American 
Practitioner. 



Lea Brothers & Co., Publishers, 706, 708 & 770 Sanson) Street, Philadelphia. 



12 Therapeutics, flateria Fledica — (Continued). 
Hare's Text-Book of Practical Therapeutics.— New (5th) Edition. 

A Text-Book of Practical Therapeutics ; With Especial Reference to 
the Application of Remedial Measures to Disease and their Employment upon a Rational 
Basis. By Hobart Amory Hare, M. D., Professor of Therapeutics and Materia Medica 
in the Jefferson Medical College of Philadelphia ; Sec. of Convention for Revision of U. S. 
Pharmacopoeia. With special chapters by Drs. G. E. de Schweinitz, Edward 
Martin and Barton C. Hirst. New (5th) and revised edition. In one octavo volume 
of 740 pages. Cloth, $3.75 ; leather, $4.75. Just ready. 
A few notices of the previous edition are appended. 



We deem the portion of the work descriptive of 
remedies admirable by reason of the clearness 
and conciseness with which it is written. The 
descriptions of diseases, though exceedingly- 
brief, are nevertheless sufficiently explicit and so 
expressed as to render the work a very practical 
text-book, and also one which will serve prac- 
titioners for ready reference. The methods of 



practical needs of every-day medicine com- 
mended it from the first to the progressive and 
working therapeutist. It is not only knowing 
what to give, but when and where to give, and 
how the drug will act in given conditions, that 
makes one a scientific practitioner rather than an 
ignorant empiric. The book in such respects 
supplies every need. The author is well known 



treatment are at once sensible and practical. The as a progressive therapeutist, and it goes without 



more experienced the practitioner who turns to 
this book for reference, the more sure will be the 
approval of the methods of treatment here pro 
posed. — The North American Practitioner. 

The fact that the fourth edition of this work has 
appeared within four years attests its value to the 
general practitioner, and its appreciation by the 
medical student. Its wide application to the 



saying that all the new or valuable drugs receive 
their lull share of attention, and it is a great deal 
to say in this, as with other features, that the book 
is up-to-date in everything pertaining to the prac- 
tical therapeutical needs of the practitioner. The 
work has also been revised in such a way as to 
make it uniform with the United States Pharma- 
copoeia. — Medical Record. 



Maisch's Materia Medica.— New (6th) Edition. Just Ready. 

A Manual of Organic Materia Medica; Being a Guide to Materia Medica 
of the Vegetable and Animal Kingdoms. For the Use of Students, Druggists, Pharmacists 
and Physicians. By John M. Maisch, Phar. D., Prof, of Materia Medica and Botany in 
the Philadelphia College of Pharmacy. New (sixth) edition, thoroughly revised by 
H. C. C. Maisch, Ph.Gr., Ph. D. In one very handsome 12mo. volume of 509 pages, with 
285 engravings. Cloth, $3.00. 

A notice of the previous edition is appended. 



We have nothing but praise for Professor 
Maisch's work. It presents no weak point, even 
for the most severe critic. The book fully sustains 
the wide and well-earned reputation of its popular 
author. After a careful perusal of the book, we 



do not hesitate to recommend Maisch's Manual] book. — Medical News. 



of Organic Materia Medica as one of the best, if not 
the best work on the subject thus far published. 
Its usefulness cannot well be dispensed with, and 
students, druggists, pharmacists and physicians 
should all possess a copy of such a valuable 



A System of Practical Therapeutics 

BY AHERICAN AND FOREIGN AUTHORS. 
Edited by HOBART AflORY HARE, H. D. 

Professor of Therapeutics and Materia Medica in the Jefferson Medical College of Philadelphia. 

In a series of contributions by seventy-eight eminent authorities. In three large 
octavo volumes of 3544 pages, with 434 illustrations. Price, per volume : Cloth, $5.00 ; 
leather, $6.00 ; half Russia, $7.00. For sale by subscription only. Address the Publishers. 
The various divisions have been elaborated by j is the treatment of disease, and a work which con- 
men selected in view of their special fitness. In j tributes to its successful management is to be 
every case there is to be found a clear and concise : looked upon as of vast use to humanity. It can- 
description of the disease under consideration, | not be denied that therapeutic resources, whether 
corresponding with the most recent and well- | the treatment be confined to the mere administra- 
established views of the subject. In treating of | tion of drugs, or allowed its more extended appli- 
the employment of remedies and therapeutical cation to the management of disease, have so 



measures, the writers have been singularly happy 
in giving in a definite way the exact methods em- 
ployed and the results obtained, both by them- 
selves and others, so that one might venture with 
confidence to use remedies with which he was 
previously entirely unfamiliar. The practitioner 
could hardly desire a book on practical thera- 
peutics which he could consult with more interest 
and profit. — The North American Practitioner. 

The scope of this work is beyond that of any 
previous one on the subject. The goal, after alJ, 



greatly multiplied within the last few years as to 
render previous treatises of little value. Herein 
will be found the great value of ii are's encyclo- 
pedic work, which groups together within a single 
series of volumes the most modern methods 
known in the management of disease. "We can- 
not commend Hare's System of Practical Thera- 
peutics too highly; it stands out first and foremost 
as a work to be consulted by authors, teachers, 
and physicians throughout the world. — Buffalo 
Medical and Surgical Journal. 



Edes' Therapeutics and Materia Medica. 

A Text-Book of Therapeutics and Materia Medica. Intended for the 
Use of Students and Practitioners. By Bobert T. Edes, M. D., Jackson Professor of 
Clinical Medicine in Harvard University. Octavo, 544 pp. Cloth, $3.50 ; leather, $4.50. 



COHEN'S HANDBOOK OF APPLIED THERA- 
PEUTICS. B«ing a Study of Principles Applic- 
able and an Exposition of Methods Employed 
in the Management of the Sick. Bv Solomon 
Solis-Cohen, M D., Professor of Clinical Medi- 
cine and Applied Therapeutics in the Philadel- 
phia Polyclinic. In one large 12mo. volume, 



with illustrations. Preparing. 
STILLE'S THERAPEUTICS AND MATERIA 
MEDICA. A Systematie Treatise on the Action 
and Uses of Medicinal .Agents, including their 
Description and History. Fourth edition, re- 
vised and enlarged. In two octavo volumes, coq- 
taining 1936 pages. Cloth, §10.00 ; leather, §12.00. 



Lea Brothers & Co., Publishers, 706, 708 & 710 Sansom Street, Philadelphia. 



Practice of Fledicine. 



13 



SEVENTH EDITION. 

FLINT'S PRACTICE OF MEDICINE 

A Treatise on the Principles and Practice of Medicine. Designed 
for the use of Students and Practitioners of Medicine. By Austin Flint, M. L>., LL. D., 
Professor of the Principles and Practice of Medicine and of Clinical Medicine in Belle- 
vue Hospital Medical College, N. Y. Seventh edition, thoroughly revised by Fred- 
erick P. Henry, M. D., Professor of Principles and Practice of Medicine in the 
Woman's Medical College of Pennsylvania, Philadelphia. In one very handsome octavo 
volume of 1143 pages, with illustrations. Cloth, $5.00 ; leather, $6.00. 

Among the large number of new books upon the 
practice of medicine which have been presented 
to the profession within the last few years, there 
is none which will stand better in the present or 
in the future than the seventh edition of this 
book. It has been a characteristic of Dr. Flint's 
book that its descriptions of clinical cases and of 
the practical side of diseases have always been 
wonderfully true to life. Further than this, we 
think the profession is to be congratulated that 
the publishers, in obtaining an editor, chose one 
so peculiarly well qualified to revise and bring up 
to date those articles in connection with which 
the greatest progress has been made in medical 
study, for Dr. Henry represents at once that side 
of professional life which appreciates all that is 
good and at the same time is not so optimistic as 
to swallow in addition much that is bad. We be- 
lieve that the profession, the teachers, and the 
students of the country will appreciate this volume 
as being one of the best all-around text-books 
which they can obtain. — Therapeutic Gazette. 



Its peculiar excellences and its breadth of con- 
ception have made it a recognized authority from 
the time its first edition appeared. The author 
was a born teacher, an indefatigable observer, a 

f>ainstaking worker and a thorough medical phil- 
osopher. His clinical pictures of diseases are 
models of graphic description, minuteness of 
detail and breadth of treatment This may appear 
to be high praise, but the work has so well earned 
its leading p'ace in medical literature that but one 
view can be expressed concerning its general 
character as a text-book. The editor has done his 
part in bringing it up to date, not only in refer- 
ence to treatment and the adaptation of the newer 
remedies, but has made numerous additions in 
the shape of the newly discovered forms of disease, 
and has elaborated much in the commoner forms 
which the recent advances have made necessary. 
The element of treatment is by no means ne- 
glected ; in fact, by the editor a fresh stimulus is 
given to this necessary department by a compre- 
hensive study of all the new and leading thera- 
peutic agents. — Medical Record. 



Hartshorne's Essentials of Practice.— Fifth Edition. 

Essentials of the Principles and Practice of Medicine. A Handbook 
for Students and Practitioners. By Henry Hartshorne, M. D., LL. D., lately Professor 
of Hygiene in the University of Pennsylvania. Fifth edition, thoroughly revised and 
rewritten. In one 12mo. vol. of 669 pages, with 144 illus. Cloth, $2.75 ; half leather, $3. 



Farquharson's Therapeutics and Materia Medica.— 4th Ed. 

A Guide to Therapeutics and Materia Medica. By Kobert Far- 
qtjharson, M. D., F. K. C. P., LL. D., Lecturer on Materia Medica at St. Mary's Hospi- 
tal Medical School, London. Fourth American, from the fourth English edition. 
Enlarged and adapted to the U. S. Pharmacopoeia. By Frank Woodbury, M. D., Pro- 
fessor of Materia Medica and Therapeutics and Clinical Medicine in the Medico-Chi- 
rurgical College of Philadelphia. In one handsome 12mo. vol. of 581 pp. Cloth, $2.50. 



It may correctly be regarded as the most modern 
work of its kind. It is concise, yet complete. 
Containing an account of all remedies that have 
a p±ace in the British and United States Pharma- 



copoeias, as well as considering all non-official but 
important new drugs, it becomes in fact a miniature 
dispensatory. — Pacific Medical Journal. 



Brace's Materia Medica and Therapeutics.— Fifth Edition. 

Materia Medica and Therapeutics. An Introduction to Rational Treat- 
ment. By J. Mitchell Bruce, M. D., F. R. C. P., Physician and Lecturer on Materia 
Medica and Therapeutics at Charing-Cross Hospital, London. Fifth edition. In one 
12mo. volume of 591 pages. Cloth, $1.50. See Students 1 Series of Manuals, page 30. 



The pharmacology and therapeutics of each drug 
are given with great fulness, and the indications for 
its rational employment in the practical treatment 
of disease are pointed out. The Materia Medica 
proper contains ah that is necessary for a medical 
student to know at the present day. The third 



part of the book contains an outline of general 
therapeutics, each of the symptoms of the body 
being taken in turn, and the methods of treat- 
ment illustrated. A lengthy notice of a book so well 
known is unnecessary.— -.Med. Chronicle. 



FLINT'S PRACTICAL TREATISE ON THE 
DIAGNOSIS, PATHOLOGY AND TREATMENT 
OF DISEASES OF THE HEART. Second re- 
vised and enlarged edition. In one octavo vol- 
ume of 550 pagps, with a plate. Cloth, $4. 

FLINT ON PHTHISIS In one octavo volume 
of 442 pages. Cloth, $3.50. 

FLINT'S ESSAYS ON CONSERVATIVE MEDI- 
CINE AND KINDRED TOPICS. In one very 
handsome royal 12mo. volume of 210 pages. 
Cloth, $1.38. 

LYONS' TREATISE ON FEVER. In one Svo. 
volume af 354 pages. Cloth, $2.25. 

HUDSON'S LECTURES ON THE STUDY OF 



FEVER. In one octavo volume of 308 pages. 
Cloth, $2.50. 

LA ROCHE ON YELLOW FEVER, in its Histori- 
cal, Pathological, Etiological and Therapeutical 
Relations. Two octavo vols., 1468 pp. Cloth, $7.00. 

BRUNTON'S PHARMACOLOGY, THERAPEU- 
TICS AND MATERIA MEDICA. Octavo, 1305 
pages, 230 illustrations. 

HERMANN'S EXPERIMENTAL PHARMACOL- 
OGY. A Handbook of Methods for Determining 
the Physiological Action of Drugs. Translated, 
with the Author's permission, and with exten- 
sive additions, by R. M. Smith, M. D. 12mo., 
199 pages, with 32 illustrations. Cloth, $1.50. 



Lea Brothers & Co., Publishers, 706, 708 & 710 Sansom Street, Philadelphia. 



14 Prac. of fledicine, Treatment, Digestive Syst. 
Lyman's Practice of Medicine. 

The Principles and Practice of Medicine. For the Use of Medical 
Students and Practitioners. By Henry M. Lyman, M.D., Professor of the Principles 
and Practice of Medicine, Rush Medical College, Chicago. In one verv handsome octavo 

Cloth, $4.75 ; leather, $o.75. 
ascertain in a short time all the necessary facts 
concerning the pathology or treatment of any dis- 
ease will find here a safe and convenient guide. — 
The Charlotte Medical Journal. 

The reader of the above volume will be at once 
struck with its excellence. Its contents are com- 
plete and concise, it is fully abreast with the times, 
and is suih a book as is needed by students and 
practitioners. The average doctor tias neither the 
time nor the patience to read through the pages 
of an encyclopedia to gain the points he desires. 
This Practice will give him all the necessary in- 
formation in a form easily grasped. The parts of 
chapters relating to differential diagnosis leave 
nothing to be desired; they show the author's 
familiarity with his subjects, and bis methods as 
a teacher. Evidently the points are not culled 
from other volumes; they bear the stamp of 
originality. In a word, the volume is up to date, 
is readable and instructive, and is far superior to 
the majority of books of the kind. — University 
Medical Magazine. 



volume of 925 pages, with 170 illustrations, 
Professor Lyman's valued and extensive expe- 
rience here reduced in text- book form, is indeed 
very valuable both to college students and physi- 
cians. In this work we have aa excellent ti eatise 
on the practice of medicine, written by one who 
is not only familiar with his subject, but who has 
also learned through practical experience in teach- 
ing what are the needs of the student and how 
to present the facts to his mind in the most readily 
assimilable form. Each subject is taken up in 
order, treated clearly but briefly, and dismissed 
when all has been said that need be said in order 
to give the reader a clear cut picture of the dis- 
ease under discussion. The reader is not con- 
fused by having presented to him a variety of 
different methocs of treatment, among which he 
is left to choose the one most easy of execution, 
but the author describes the one whir>h is, in his 
judgment, the best. This is as it should be. The 
student and even the practitioner, should be 
taught the most approved method of treatment. 
The practical and busy physician, who wants to 



The Year-Book of Treatment for 1895, 

A Comprehensive and Critical Review for Practitioners of Medi- 
cine and Surgery. In one 12mo. vol. of 495 pages. Cloth, $1.50. 

**# For special commutations with periodicals see pages 1 and 2. 



It would be difficult indeed to imagine a book 
more nearly suited to the every day need3 of the 
medical practitioner or writer than this. The con- 
tributors to this volume are among the most promi- 
nent and well-known writers and teachers of the 
day, and their articles and opinions will be appre- 
ciated by all who are fortunate and wise enough 
to secure them. It is the very book the busy 



practitioner needs. He can find anything pertain- 
ing to any subject in a moment's time, and he may 
rest assured that it is the most modern and reliable 
view now accepted. It, year by year, keeps him 
apprised of important advances in all branches 
of medicine, and presents them in a well-con- 
densed and classified form. — The Charlotte Med- 
ical Journal, May, 1895. 



The Year-Books of Treatment for 1891, 1892, and 1893. 



12mos., 485 pages Cloth, $1.50 each. 



The Year-Books of Treatment for 1888 and 1887. 



Habershon on the Abdomen. 

On the Diseases of the Abdomen ; Comprising those of the Stomach, and 
other parts of the Alimentary Canal, (Esophagus, Cascum, intestines and Peritoneum. By 
S. O. Habershon, M. D., Senior Physician to and late Lecturer on Principles and Prac- 
tice of Medicine at Guy's Hospital, London. Second American from third enlarged and 
revised English edition. In one handsome octavo vol. of 554 pages, with illus. Cloth, $3.50. 
This valuable treatise on diseases of the stomach rectum. A. fair proportion of each chapter is 
and abdomen will be found a cyclopaedia of infor- 
mation, systematically arranged, on all diseases of 
the alimentary tract, from the mouth to the 



devoted to symptoms, pathology, and therapeutics. 
— New York Medical Journal. 



TANNER'S MANUAL OF CLINICAL MEDICINE I 
AND PHYSICAL DIAGNOSIS. Third American 
from the second London edition. Revised am v ' 
enlarged by Tilbury Fox. M.D. In one 12mo. 
volume of 362 pp. with illus. Cloth, $1.50 

DAVIS' CLINICAL LECTURES ON VARIOUS 
IMPORTANT DISEASES. By N. S. Dins, I 
M. D. Edited by Frank H. Davis, M. D Second 
edition. 12mo. 287 pages. Cloth,' $1 .1- 

WALSHE ON THE DISEASES OF THE HEART 
AND GREAT VESSELS. Third American edi- 
tion. In 1 vol. 8vo., 418 pp. Cloth, $3.00. 

HOLLAND'S MEDICAL NOTES AND REFLEO ' 
TIONS. 1 vol. 8vo., pp. 493. Cloth, $3.50. 

TODD'S CLINICAL LECTURES ON CERTAIN 
ACUTE DISEASES. In one octavo volume of 
320 pages. Cloth. $2.50. 

FLINT'S PRACTICAL TREATISE ON THE 
PHYSICAL EXPLORATION OF THE CHEST 
AND THE DIAGNOSIS OF DISEASES AF- 
FECTING THE RESPIRATORY ORGANS. 
Second and revised edition. In one handsome 
octavo volume of 591 pages. Cloth, $4.50. 

STURGES' INTRODUCTION TO THE STUDY | 



OF CLINICAL MEDICINE. Being a Guide to 
the Investigation of Disease. In one handsome 
12mo. volume of 127 pages. Cloth, $1.25. 

REYNOLDS' SYSTEM OF MEDICINE. With 
notes and additions by Henry Hartshorne, A.M., 
M. D. Three octavo volumes, containing 3056 
double-columned pages, with 317 illustrations. 
Price per volume, cloth, $5.00; sheep, $6.00 ; half 
Russia, $6.50. Subscription only. 

WATSON'S LECTURES ON THE PRINCIPLES 
AND PRACTICE OF PHYSIC. Edited with 
additions, and 190 illustrations, by Henry Harts- 
horxe, A.M., M.D. In two large octavo volumes 
of 1840 pages Cloth, $9.00; leather, $11.00. 

PEPPER'-; SYSTEM OF PRACTICAL MEDI- 
CINE BY AMERICAN AUTHORS Edited by 
William Pepper, M. D., LL. D., Provost and 
Professor of the Tneoryand Practice of Medi- 
cine and of Cliuical Medicine in the Univer- 
sity of Pennsylvania. The complete work, in 
five volumes, contains 5573 pages, with 193 illus- 
trations. Price, per volume, cloth, $5; leather, 
$3; half Russia, $7. Subscription only. 



Lea Brothers & Co., Publishers, 706, 708 & 710 Sansom Street, Philadelphia. 



Practice of fledicine, Diagnosis, Heart. 15 



Musser's Medical Diagnosis. 

A Practical Treatise on Medical Diagnosis. For the Use of Students 
and Practitioners. By John H. Mdsser, M. D., Assistant Professor of Clinical Medicine, 
University of Pennsylvania, Philadelphia. !n one very handsome octavo volume of 873 
pages, with 162 illustrations and 2 colored plates. Cloth, |5; leather, $6. 
The aim of the author 



has been to make 
the work eminently practical. Dr. Musser 
has succeeded in bringing together a large and 
valuable collection of clinical data drawn from his 
own extended experience and from exhaustive 
literary research, and has presented them in an 
unusually clear and concise manner. In brief, 
the book is thoroughly modern, readable and in- 
structive, and, we believe, superior to any work of 
the kind before the profession.— University Medical 
Magizine. 

Modern methods of medical teaching and study 
have rendered treatises like the present an abso- 
lute necessity. The present work is to be com- 
mended alike for its logical arrangement, accurate 
observation and clearness of expression. The 
chapter on bacteriology is especially commenda- 
ble, because it contains everything practically 
necessary for clinical work. — Medical Record. 

The book should receive a hearty reception from 
students and medical men; it contains much in- 



formation essential to good, scientific medical 
work. It is with pleasure that we can state that 
the work has been adopted as a text- book at the 
Johns Hopkins Medical School and Harvard Uni- 
versity, and that it has met with marked approval 
in other teaching centres. — International Medical 
Magazine. 

The whole book impresses one as being the 
concentration of a very thorough knowledge of 
all the fact* resorted to in the making of a careful 
diagnosis by means of modern methods. Dr. 
Musser's book will at once take a prominent and 
permanent position among the text-books of the 
medical schools of the country, and we recom- 
mend it most highly to those practitioners who 
wish not only to get the views of the general pro- 
fession in regard to important points of diagnosis, 
but who also desire a work in which the author 
expresses his own opinions, based upon careful 
observation and wide experience. — The Thera- 
peutic Gazette. 



Flint on Auscultation and Percussion.— Fifth Edition. 

A. Manual of Auscultation and Percussion ; Of the Physical Diagnosis 
of Diseases of the Lungs and Heart, and of Thoracic Aneurism. By Austin Flint, M. D., 
LL. D., Professor of the Principles and Practice of Medicine in Bellevue Hospital Medi- 
cal College, New York. Fifth edition. Edited by James C. Wilson, M. D., Lecturer 
on Physical Diagnosis in the Jefferson Medical College, Philadelphia. In one hand- 
some royal 12mo. volume of 274 pages, with 12 illustrations. 

Whitla's Dictionary of Treatment. 

A Dictionary of Treatment ; or Therapeutic Index, including 
Medical and Surgical Therapeutics. By William Whitla, M. D., Professor 
of Materia Medica and Therapeutics in the Queen's College, Belfast. Revised and adapted 
to the United States Pharmacopoeia. In one square, octavo vol. of 917 pp. Cloth, $4.00. 



We have already dictionaries of medicine and 
dictionaries of surgery; Dr. Whitla now provides 
us with a dictionaryof treatment. And reference 
to the volume shows that it really is what it 
professes to be. The several diseased condi- 
tions are arranged in alphabetical order, and 
the methods— medical, surgical, dietetic, and 
climatic— by which they may be met, considered. 
On every page we find clear and detailed direc- 
tions for treatment supported by the author's 
personal authority and experience whilst the 
recommendations of other competent observers 
are also critically examined. The book abounds 
with useful, practical hints and suggestions, and 



the younger practitioner will find in it exactly the 
help he so often needs in the treatment both of 
those who are ill, and those who are ailing. At the 
same time the most experienced members of the 
profession may usefully consult its pages for the 
purpose of learning what is really trustworthy in 
the later therapeutic developments. The Diction- 
ary is, in short, the recorded experience of a prac- 
tical scientific therapeutist, who has carefully 
studied diseases and disorders at the bed-side and 
in the consulting-room, and has earnestly ad- 
dressed himself to the cure and relief of his 
patients. — The Glasgow Medical Journal. 



Taylor's Index of Medicine.— Just Ready. 

An Index of Medicine. By Seymour Taylob, M. D., M. E. C. P., Assistant 
Physician to the West London Hospi lal. In one 12mo. vol. of 802 pages. Cloth, $3.75. 

The author ha3 prepared a work of great value systems of the body are considered, and the 
alike to physicians and students. The volume is j cause, symptoms, pathology, treatment and 
a concise "Practice of Medicine," the diseases j prognosis of each affection are succinctly stated, 
being grouped systematically in order to secure I Numerous illustrations together with tabulations 
for the reader the many advantages resulting | of differential diagnosis, tests, etc., elucidate the 
from rational arrangement. After valuable chap- text and condense a great amount of necessary 
ters on "Disease," "General Pathology," "Gen knowledge in the clearest manner. The work is 
eral Diseases," "Specific Infectious Diseases" | one which merits and will doubtless obtain a 
and "Specific Fevers," the various organs and i wide popularity.— The St. Louis Clinique, May, 1895. 

Fothergill's Handbook of Treatment.— Third Edition. 

The Practitioner's Handbook of Treatment ; Or, The Principles of 
Therapeutics. By J. Milner Fothergill, M. D., Edin., M. E. C. P., Lond., Physician 
to the City of London Hospital for Diseases of the Chest. Third edition. In one 8vo. 
volume of 681 pages. Cloth, $3.75 ; leather, $4.75. 

This is a wonderful book. If there be such a together in a single chapter, and the relations 
thing as "medicine made easy," this is the work to between the two clearly stated, cannot fail to prove 
accomplish this result.— Virainia Medical Monthly, a great convenience to many thoughtful but busy 

To have a description of the normal physiologi- physicians. The practical value of the volume is 
cal processes of an organ and of the methods of greatly increased by the introduction of many 
treatment of its morbid conditions brought prescriptions.— New York Medical Journal. 



BROADBENT ON THE PULSE. In one 12mo. volume of 312 pages. Cloth, $1.75. See Series oj 
Clinical Manuals, page 30. 

Lea Brothers & Co., Publishers, 706, 708 & 710 Sansom Street, Philadelphia. 



16 Practice, Electricity, Cholera, Food, Hygiene. 
Hayem & Hare's Physical & Natural Therapeutics.— Just Ready. 

Physical and Natural Therapeutics. The Eemedial Use of Heat, 
Electricity, Modifications of Atmospheric Pressure, Climates, and Mineral Waters. By 
Georges Hayem, M.D., Professor of Clinical Melicine in the Faculty of Medicine of 
Paris. Edited with the assent of the author, by Hobart Amory Hare, M.D., Professor 
of Therapeutics in the Jefferson Medical College of Philadelphia. In one handsome 
octavo volume of 414 pages with 113 engravings. Cloth, $3.00. 

For many diseases the most potent remedies lie outside of the Materia Medica, a fact 
yearly attaining wider recognition. Within this large range of applicability physical 
agencies when compared with drugs are more direct and simple in their results. Medical 
literature has long been rich in treatises upon medicinal agents, but an authoritative 
work upon the other great branch of therapeutics has until now been a desideratum. The 
author and editor of this work enjoy equal standing, and the volume is certain to command 
attention and to render wide-spread service. The section on Climate, rewritten by Professor 
Hare, will for the first time, place the abundant resources of our own countiy at the 
intelligent command of American practitioners. The extended section on Medical Electricity, 
likewise rewritten, conforms to the American development of this subject, and explains the 
many excellent forms of apparatus readily available in this country. 

Herrick's Diagnosis.— Just Ready. 

A Handbook of Diagnosis. By James B. Herrick, M.D., Adjunct Pro- 
fessor of Medicine, Rush Medical College, Chicago. In one handsome 12mo. volume of 
429 pages, with 80 engravings and 2 colored plates. Cloth, $2.50. 

This work affords students a compendious guide to the art of identifying disease. Prac- 
titioners likewise will find in its carefully prepared and well-illustrated pages a convenient 
means of refreshing and supplementing their knowledge of a department of medicine which 
underlies rational and successful treatment. 



Yeo's Medical Treatment. 

A Manual of Medical Treatment or Clinical Therapeutics. By 

1. Burney Yeo, M. D., F. E. C. P., Prof, of Clinical Therapeutics in King's Coll., London. 
In two 12mo. volumes containing 1275 pages, with illustrations. Cloth, $5.50. 

The discussion of the different ailments has a j tion, which is a feature that cannot be too highly 
distinctly practical turn toward the main purpose j commended. It cannot fail to be an exceedingly 
of the book. Standard formulae are introduced useful, suggestive and instructive work to the 
from eminent practitioners, and all the drugs of physician who wishes to be well up ia the present 
recognized value are grouped in the order of their advanced and scientific therapeutics of the day. — 
importance. The dosage receives careful atten- Medical Record. 

Yeo on Food in Health and Disease. 

Food in Health and Disease. By I. Burney Yeo, M.D., F.R.C. P., 

Professor of Clinical Therapeutics in King's College, London In one 12mo. volume of 

590 pages. Cloth, $2 00. See Series of Clinical Manuals, page 30, 

compass, and he has arranged and digested his 
materials with skill for the use of the practitioner. 
We have seldom seen a book which more thor- 
oughly realizes the object for which it was written 
than this little work of Dr. Yeo.— British Medical 



Dr. Yeo supplies in a compact form nearly all that 
the practitioner requires to know on the subject of 
diet. The work is divided into two parts — food in 
health and food in disease. Dr. Yeo has gathered 
together from all quarters an immense amount of 
useful information within a comparatively small 



Journal. 



BartMow on Cholera. 

Cholera : Its Causes, Symptoms, Pathology and Treatment. By 

Roberts Bartholow, M. D., LL. D., Emeritus Professor of Materia Medica, General 
Therapeutics and Hygiene in the Jefferson Medical College of Philadelphia. In one 12mo. 
volume of 127 pages, with 9 illustrations. Cloth, $1.25. 

Richardson's Preventive Medicine. 

Preventive Medicine. By B. W. Richardson, M. D., LL. D., F. R. S., Fel- 
low of the Royal Coll. of Phys., London. In one 8vo. vol. ot 729 pp. Cloth, $4; leather, $5. 

There is perhaps no similar work written for scholarly ; the discussion of the question of disease 
the general public that contains such a complete, is comprehensive, masterly and fully abreast with 
reliable and instructive collection of data upon the latest and best knowledge on the subject, and 
the diseases common to the race, their origins, the preventive measures advised are accurate, 
causes, and the measures for their prevention, j explicit and reliable.— TheAmerican Journal of the 
The descriptions of diseases are clear, chaste and ; Medical Sciences 



BARTHOLOW'S PRACTICAL TREATISE ON 
THE APPLICATIONS OF ELECTRICITY TO 
MEDICINE AND SURGERY. By Roberts 
Bartholow, A.M., M.D., LL.D., Emeritus Pro- 
fessor of Materia Medica and General Thera- 
peutics in the Jefferson Med. Coli. of Philadel- 
phia, etc. Third edition. In one octavo volume 
of 308 pages, with 110 illustrations. 

PAVY'S TREATISE ON THE FUNCTION OF DI- 
GESTION; its Disorders and their Treatment. 
From the second London edition. In one octavo 
volume of 238 pages. Cloth, $2.00. 



SCHREIBER'S MANUAL OF TREATMENT BY 
MASSAGE AND METHODICAL MUSCLE EX- 
ERCISE. Translated by Waiter Mendelson, 
M.D., of New York. In one 8vo. volume of 274 
pp., with 117 engravings. 

CHAMBERS' MANUAL OF DIET AND REGIMEN 
IN HEALTH AND SICKNESS. In one hand- 
gome octavo volume of 302 pp. Cloth, 82.75. 

STILLE ON CHOLERA: Its Origin, History, 
Causation, Symptoms, Lesions, Prevention and 
Treatment. In one handsome 12mo. volume of 
163 pages, with a chart. Cloth, $1.25. 



Lea Brothers & Co., Publishers, 706, 708 & 710 Sansom Street, Philadelphia. 



Throat, Nose, Lungs, Hind, Nerves, 



17 



Seiler on the Throat and Nose.— Fourth Edition. 

A Handbook of Diagnosis and Treatment of Diseases of the 
Throat, Nose and Naso-Pharynx. By Carl Seiler, M.D., Lecturer on 
Laryngoscopy in the University of Pennsylvania. Fourth edition. In one handsome 
12nio. volume of 414 pages, with 107 illustrations and 2 colored plates. Cloth, $2.25. 

1 come expeit in the use of the laryngeal mirror, a 



This little book is eminently practical, and will 
prove of interest not only to the specialist, but to 
:he general practitioner as well. It deals with the 
subject in a clear and distinct manner, and the 
text i* copiously il.ustrated with diagrams and 
colored plates. *S;> little attention is paid ordi- 
narily to the examination of the larynx that the 
need'of such a book has long been felt. By con 
suiting its pa^es anyone can learn the necessary 
manipulations, and, "by a little practice, soon be- 



method of examination too often neglected. The 
anatomy of the larynx is explained with especial 
care, and the operative procedures for various 
diseases of the throat, tonsils, etc., are carefully 
explained. Approved methods of tieatment are 
dealt with in a very satisfactory way, and all the 
most useful remedial agents are described. — 
International Medical Magazine. 



Browne on the Throat and Nose.— Fourth Edition 

The Throat and Nose and Their Diseases. By Lennox Browne, 
F. E. C. S., E., Senior Physician to the Central London Throat and Ear Hospital. 
Fourth and enlarged edition. In one imperial octavo volume of 751 pages, with 120 
illustrations in color, and 235 engravings on wood. Cloth, $6.50. 

The subject is here exhaustively treated on 
lines of thorough acquaintance with the anatomy, 
the physiology and physics of the organs involved 
and the pathology of the disease to which they 
are subject. To the author we have awarded the 
credit of having added to a thorough understand- 
ing of the diseases with which he deals the choice 
of the best treatment afforded by the present state 



of knowledge. — The Amer, Practitioner and News. 

Although quite complete enough for the use of 
specialists, it is at the same time so clear as to be 
of daily value to the general practitioner, who will 
find at the end of the volume a number of well- 
tried formulas most in vogue at the London hos- 
pitals for diseases of the throat.— The Canada 
Medical Record. 



Tuke on the Influence of the Mind on the Body. 

Illustrations of the Influence of the Mind upon the Body in 
Health and Disease. Designed to elucidate the Action of the Imagination. By 
Daniel Hack Tuke, M. D., Joint Author of the Manual of Psychological Medicine, 
etc. New edition. Thoroughly revised and rewritten. In one 8vo. volume of 467 pages, 
with 2 colored plates. Cloth, $3 00. 



It is impossible to perase these interesting chap- 
ters without being convinced of the author's per- 
fect sincerity, impartiality, and thorough mental 
grasp. Dr. Tuke has exhibited the requisite 
amount of scientific address on all occasions, and 
the more intricate the phenomenathe more firmly 
has he adhered to a physiological and rational 



method of interpretation. Guided by an enlight- 
ened deduction, the author has reclaimed for 
science a most interesting domain in psychology, 
previously abandoned to charlatans and empirics. 
This book, well conceived and well written, must 
commend itself to every thoughtful understand- 
ing. — New York Medical Journal. 



Ross on Diseases of the Nervous System. 

A Handbook on Diseases of the Nervous System. By James 
Eoss, M. D., F. K. C.P., LL.D., Senior Assistant Physician to the Manchester Koyal 
Infirmary. In one octavo vol. of 725 pages, with 184 illus. Cloth, $4.50; leather, $5.50. 

Clouston on Mental Diseases. 

Clinical Lectures on Mental Diseases. By Thomas S. Clouston, 
M. D., Lecturer on Mental Diseases in the University of Edinburgh. With an Appen- 
dix, containing an Abstract of the Statutes of the United States and of the Several 
States and Territories relating to the Custody of the Insane. By Charles F. Folsom, 
M. D., Ass't Professor of Mental Diseases, Med. Dep. of Harvard Univ. In one octavo 
volume of 543 pages, with eight lithographic plates, four of which are colored. Cloth, $4. 
JiH^Dr. Folsom's Abstract also separate, in one 8vo. vol. of 108 pages, Cloth, $1.50. 

Playfair on Nerve Prostration and Hysteria. 

The Systematic Treatment of Nerve Prostration and Hysteria. 

By W. S. Playfair, M. D., F. B. C. P. In one 12mo. volume of 97 pages. Cloth, $1.00. 



savage on insanity and allied neu- 

KOSES. In one 12mo. volume of 551 pages, with 
18 illustrations. Cloth, $2.00. See Serks of Clin- 
ical Manuals, page 30. 

BLANDFORD ON INSANITY AND ITS TREAT- 
MENT. Lectures on the Treatment, Medical 
and Legal, of Insane Patients. In one very 
handsome octavo volume. 

JONES' CLINICAL OBSERVATIONS ON FUNC- 
TIONAL NERVOUS DISORDERS. Second 
American Edition. In one handsome octavo 
volume of 340 pages. Cloth, $3.25. 

BROWNE ON KOCH'S REMEDY IN RELATION 
TO THROAT CONSUMPTION. In one octavo 
volume of 121 pages, with 45 illustrations, 4 of 
which are colored, and 11 charts, Cloth, $1.50. 

FULLER ON DISEASES OF THE LUNGS AND 



AIR-PASSAGES. Their Pathology, Physical Di- 
agnosis, Symptoms and Treatment. From the 
second and revised English edition. In one 
octavo volume of 475 pages. Cloth, $3.50. 

SLADE ON DIPHTHERIA; its Nature and Treat- 
ment, with an account of the History of its Pre- 
valence in various Countries. Second and revised 
edition. In one 12mo. vol., 158 pp. Cloth, $1.25. 

SMITH ON CONSUMPTION ; its Early and Reme- 
diable Stages. 1 vol. 8vo., 253 pp. Cloth, $2.25. 

LA ROCHE ON PNEUMONIA. 1 vol. Svo. of 490 
pages. Cloth, $3.00. 

WILLIAMS ON PULMONARY CONSUMPTION; 
its Nature, Varieties and Treatment. With an 
analysis of one thousand cases to exemplify its 
duration. In one 8vo. vol. of 303 pp. Cloth, $2.50. 



Lea Brothers & Co., Publishers, 706, 708 & 710 Sansom Street, Philadelphia. 



18 Nervous and flental Diseases, Histology. 
Dercum on Nervous Diseases— Just Ready. 

A Text-Book on Nervous Diseases. By American Authors. Edited 
bv F. X. Derccm, M.D., Clinical Professor of Diseases of the Nervous System in the 
Jefferson Medical College, Philadelphia. In one handsome octavo volume of 1054r 
pages, with 341 engravings and 7 colored plates. Cloth, $6.00 ; leather, $7.00. 

LIST OF CONTRIBUTORS. 

N. E. Brill, M.D. S Weir Mitchell, M.D. 

Charles W. Burr, M.D. C. A. Herter, M.D. Charles A. Oliver, M.D. 

Joseph Collins, M.D. George W. Jacoby, M.D. William Osler, M.D. 

Charles L. I'ana, M.D. William W. Keen, M.D. Frederick Peterson, M.D. 

F. X. Dercum, M.D. Philip Coombs Knapp, M.D. Morton Prince, M.D. 

Geo. E. de Schweinitz, M.D. James Hendrie Lloyd, M.D. Wharton Sinklek, M.D. 

E. D. Fisher, M. D. Charles K. Mills, M.D. M. Allen Starr, M.D. 

Landon Carter Gray, M.D. James C. Wilson, M. D. 

The prevailing impression that Nervous Diseases present peculiar difficulties possibly 
arises not so much from the nature of the subject as from the manner in which it has generally 
been presented, a belief which has led, after careful study, to the somewhat novel arrange- 
ment of this work. In brief, the general affections are considered first, and attention is then 
progressively directed to those which are more and more special. The choice of subjects and 
the space devoted to each have been arranged with special reference to practical needs, and it 
is believed that the mode of handling details is conducive to clearness, utility and complete- 
ness. A glance at the List of Contributors will show that this volume represents the views of 
gentlemen widely recognized as authorities in neurological science, and especially known in 
connection with the subjects assigned to them. The work is likewise representative of our 
great medical schools, and hence it embodies not only high authority but is likewise illustra- 
tive of the best methods of instruction. Free use has been made of illustrations in black 
and colors. The series of pictures is largely original. 

Gray on Nervous and Mental Diseases.— New (2d) Ed. Just Ready. 

A Practical Treatise on Nervous and Mental Diseases. By Landon 
Carter Gray, M.D., Professor of Diseases of the Mind and Nervous System in the New 
York Polyclinic. New (2d) edition. In one very handsome octavo volume of 728 pages, 
with 172 engravings and 3 col -red plates. Cloth, $4.75 ; leather, $5.75. 

The period of less than two years which has sufficed to exhaust the first edition of this 
work has witnessed epoch-making discoveries in the data of the science, and the opportunity 
thus presented has been fully utilized in the revision now at the command of the profession. 
Dr. Gray's book is notable for its clear, adequate and masterly exposition of both nervous and 
mental diseases within the limits of a single convenient volume. These affections, owing to 
their widespread prevalence and their peculiarities in this country, possess unrivalled import- 
ance for American physicians. Their close interrelation gives especial value to an authorita- 
tive work which handles them in proper conjunction. The series of illustrations abounds in 
typical portraits, admirable engravings and clear diagrams, and in the present edition it has 
been enriched with colored plates. 

Mitchell on Nerve Injuries and Their Treatment.— In Press. 

Remote Consequences of Injuries of Nerves and Their Treat- 
ment. An examination of the present condition of wounds received in 1863-5, with 
additional illustrative cases. By John K. Mitchell, M. D., Assistant Physician to the 
Orthopaedic Hospital and Infirmary for Nervous Diseases, Philadelphia. In one hand- 
some 12mo. volume of 239 pages, with 12 illustrations. Cloth, $1.75. Just ready. 

The author has chosen a subject of great clinical importance to physicians as well as to 
surgeons. Injuries of the nerves are common in civil as well as in military life and lead to 
various painful and intractable conditions. Dr. Mitchell has had access to authentic records 
covering thirty years, and his researches arrive at important results based upon an ample 
number of cases "under observation for a prolonged period. 



Hamilton on Nervous Diseases.— Second Edition. 

Nervous Diseases ; Their Description and Treatment. By Allen McLane 
Hamilton, M. D., Attending Physician at the Hospital for Epileptics and Paralytics, 
Blackwell's Island, N. Y. Second edition, thoroughly revised and rewritten. In one 
octavo volume of 598 pages, with 72 illustrations. Cloth, $4.00. 

Klein's Histology.— Fourth Edition. 

Elements of Histology. By E. Klein, M. D., F. R. S., Joint Lecturer on 
General Anatomy and Physiology in the Medical School of St. Bartholomew's Hospital, 
London. Fourth edition. In one 12mo. volume of 376 pages, with 194 ilius. Limp 
cloth, $1.75. See Students 7 Series of Manuals, page 30. 



PEPPER'S SURGICAL PATHOLOGY. In one 
pocket-size 12mo. volume of 511 pages, with 81 



illustrations. Limp cloth, red edges, $2.00 See 
Students' Series of Manuals, page 30. 



Lea Brothers & Co., Publishers, 706, 708 & 710 Sansom Street, Philadelphia. 



Pathology, Histology, Bacteriology, 



19 



Green's Pathology and Morbid Anatomy.— New (8th) Edition. 

Pathology and Morbid Anatomy. By T. Henry Green, M. D., Lecturer 
on Pathology and Morbid Anatomy at Charing-Cro?s Hospital Medical School, London. 
Seventh American from the eighth and revised English edition. In one handsome oclavo 
volume of 595 pages, with 224 engravings, and a colored plate Cloth, $2.75. Just ready. 
Green's Pathology and Morbid Anatomy has long been unquestionably the leading text- 
book on its subjects in English-speaking schools of medicine, a r ~ 
l American and eitdit English editions. The present iss 



fact attested by the demand 
c n.ngiLsn eiuuons. me present issue has been throughly revised 
to represent the latest knowledge, new chapters being added, and every page bearing evidence 
of change. The notable list of illustrations has been enriched by the addition of sixty new 
engravings and a colored plate. 

Gibbes' Practical Pathology and Morbid Histology. 

Practical Pathology and Morbid Histology. By Heneage Gibbes, 
M. D., Professor of Pathology in the University of Michigan, Medical Department. In 
one very handsome 8vo. vol. of 314 pp., with 60 illus., mostly photographic. Cloth, $2.75. 

the tissues for examination, cut, stain and mount 



In fulness of directions as to the modes of 
investigating morbid tissues the book leaves 
little to be desired. The work is throughout 
profusely illustrated with reproductions of micro- 
photographs. We may say that the practical 
histologist will gain much useful information 
from the book. — The London Lancet. 

The student of morbid histology and bacteri- 
ology has at his hand, in tnis neat volume of some 
three hundred pages, a most excellent guide and 
one which, unless he be a very advanced student, 
he cannot afford to be without. The work is 
divided into four parts, the first, that of practical 
pathology, containing clear and precise directions 
in histological technique, showing how to prepare 



sections, etc. The second part deals with bacteri- 
ology, with the different forms of cultivation, 
microscopic examinations of the bacteria, etc. 
The third part, which comprises more than half 
the book, treats of morbid histology. This partis 
illustrated with a great number of beautiful photo- 
micrographs in which the microscopic field is 
reproduced with a distinctness that is really 
remarkable. Tne fourth part contains some very 
practical instruction on photography with the 
microscope. Works like this of Dr. Gibbes will soon 
popularize histology among the profession at large, 
whereas it is now to a large number of physicians 
almost a sealed book. — Medical Record. 



Senn's Surgical Bacteriology.— Second Edition. 

Surgical Bacteriology. JBy Nicholas Senn, M. D., Ph. D., Professor of 
Surgery in Rush Medical College, Chicago. New (second) edition. In one handsome 
octavo of 268 pp., with 13 plates, of which 10 are colored, and 9 engravings. Cloth, $2.00. 



The book is really a systematic collection in the 
most concise form of such results as are published 
in current medical literature by the ablest workers 
in this field of surgical progress ; and to these are 
added the author's own views and the results of 
his clinical experience and original investigations. 
The book is valuable to the student, but its chief 
value lies in the fact that such a compilation 



makes it possible for the busy practitioner, whose 
time for reading is limited and whose sources of 
information are often few, to become conversant 
with the most modern and advanced ideas in sur- 
gical pathology, which have "laid the foundation 
for the wonderful achievements of modern sur- 
gery." — Annals of Surgery. 



Abbott's Bacteriology.— New (2d; Edition. 

The Principles of Bacteriology : a Practical Manual for Students and 
Physicians. By A. C. Abbott, M. D., First Assistant, Laboratory of Hygiene, University 
of Pennsylvania, Philadelphia. New (2d) edition, thoroughly revised and greatly 
enlarged. In one very handsome 12mo. volume of 472 pages, with 94 illustrations, of 
which 17 are colored. Cloth, $2.75. 



Its scope has been much extended, so that it 
now contains all that is necessary for a beginner 
to learn in order to gain a practical working 
knowledge of the subject. Ic is particularly 
adapted to the wants of students and practitioners 
who wish to pursue their study without the aid of 
an instructor. — Medicine, 

The instructions for methods of work are all 
lucid and concise. It is the most satisfactory and 
comprehensive book on practical bacteriology in 
our language.— Chicago Clinical Review, Nov., 1894. 

The second edition has been much enlarged by 



the addition of much new matter. Its illustra- 
tions, partly colored, are helpful in the elucidation 
of the text. Ample instruction is given as to 
needed apparatus, cultures, stainings, microscop- 
ic examinations, etc. The pathogenic bacilli are 
fully described both by the text and illustrations, 
and the methods of conducting examinations are 
fully set forth. It will win its way and become a 
favorite. — Virginia Medical Monthly. 

On the whole the book is one of the best of its 
kind and the most practical in the English lan- 
guage. — Maryland Medical Journal. 



Goats' Treatise on PatMogy. 

A Treatise on Pathology. By Joseph Coats, M. D., F. F. P. S., Patholo- 
gist to the Glasgow Western Infirmary. In one very handsome octavo volume of 829 
pages, with 339 beautiful illustrations. Cloth, $5.50 ; leather, $6.50. 



Medical students as well as physicians, who 
desire a work for study or reference, that treats 
the subjects in the various departments in a very 
thorough manner, but without prolixity, will cer- 
tainly give this one the preference to any with 
which we are acquainted. It sets forth the most 
recent discoveries, exhibits, in an interesting 



manner, the changes from a normal condition 
effected in structures by disease, and points out 
the characteristics of various morbid agencies, 
so that they can be easily recognized. But, not 
limited to morbid anatomy, it explains fully how 
the functions of organs are disturbed by abnormal 
conditions. — Cincinnati Medical News. 



ScMfer's Histology.— Fourth Edition. 

The Essentials of Histology. By Edward A. Schafer, F. E.S., Jodrell 
Professor of Physiology in University College, London. New (fourth) edition. In one 
octavo volume of 311 pages, with 325 illustrations. Cloth, $3.00. 



PAYNE'S MANUAL OF GENERAL PATHOL- 
OGY. Designed as an Introduction to the Prac- 
tice of Medicine. By Joseph F. Payne, M. D., 



F. R. C. P., Lecturer on Pathological Anatomy, 
St. Thomas' Hospital, London. 



Lea Brothers & Co., Publishers, 706, 708 & 710 Sansom Street, Philadelphia. 



20 



Surgery. 



Ashhurst's Surgery.— Sixth Edition. 

The Principles and Practice of Surgery. By John Ashhurst, Jr. 
M. D., Professor of Surgery and Clinical Surgery in the Univ. of Penna., Surgeon to the 
Penna. Hospital, Philadelphia, Sixth edition, enlarged and thoroughly revised. 
Octavo, 1161 pages, 656 engravingsand a colored plate. Cloth, $6.00 ; leather, $7.00. 

. In this edition he ha9 incorporated an ac- 
it of the more important recent observations in 



We have yet to see the same amount of scholarly 
and extensive information, on the subject of surgery 
in any other single volume — seldom in a number of 
volumes. As a masterly epitome of what has been 
said and done in surgery, as a succinct and logical 
statement of the principles of this subject, as a 
model text-book, we do not know its equal. It is 
the best single text-book of surgery that we have 
yet seen in this country. — New York Post Graduate. 

The author has been before the surgical world 
so long and is so versatile and resourceful that 
his several editions are rapidly taken up. 
Ashhurst has taken great pains to render this 
sixth edition fully equal to the demands of the 
present, and has constructed it on lines which 
merit a continuance of the confidence of the profes- 



sion. 

count oi the more important recent observations in 
surgical science, as well as such novelties in sur- 
gical practice as meritthe classification ofimprove- 
ments. Dr. Charles B. Nancrede, of Ann Arbor, 
has contributed a new chapter on surgical bacteri- 
ology; Dr. Barton C. Hirst has revised the sections- 
on gynecological subjects; and Drs. George E. 
de Schweinitz and B. Alexander Randall have re- 
vised the chapters on diseases of the eye and ear. 
Those surgeons who possess earlier editions of 
Ashhurst's treatise will make haste to obtain this 
new one, and those who are not familiar with the 
work will necessarily add it to their libraries. 
— Buffalo Medical and Surgical Journal. 



Young's Orthopedic Surgery. 

A Manual of Orthopedic Surgery, for Students and Practi- 
tioners. By James K. Young, M. D., Instructor in Orthopaedic Surgery, University of 
Pennsylvania, Philadelphia. In one octavo volume of 446 pages, with 285 illustrations. 
Cloth, $4; leather, $5. 



The present work will be found to meet a want 
among students in acquiring a knowledge of the 
subject, and among practitioners who constantly 
see a greater or less number of deformities and 
who desire information regarding the most 
recent views on the pathology and treatment of 
this subject. Dr. Young's large experience has 
particularly fitted him for the preparation of this 
work, which is based upon his personal observa- 
tions, although the literature of the subject has 
been carefully sifted, and whatever of import- 
ance he has thus obtained has been made full 
use of, due credit being given. The pathology 
will be found to correspond with the most 



approved modern views, and the treatment is 
very thoroughly and comprehensively considered. 
Especial attention has been given to the mechani- 
cal part of the subject. A very valuable feature 
of the work is the large number of excellently- 
executed drawings which illustrate the text. In 
those cases in which doubt is apt to occur, or in 
which the symptoms may be obscure, the differ- 
ential diagnosis has been very fully given. This 
ground has been well covered, and the work 
may be relied upon as reflecting the present 
position of the subject of which it treats. — Uni' 
versity Medical Magazine. 



Roberts' Modern Surgery. 

The Principles and Practice of Modern Surgery. For the use of Stu- 
dents and Practitioners of Medicine and Surgery. By John B. Koberts, M. D., Prof, of 
Anatomy and Surgery in the Philadelphia Polyclinic. Prof, of Surgery in the Woman's 
Medical College of Pennsylvania. Lecturer in Anatomy in the Univ. of Penna. Octavo, 
780 pages, 501 illustrations. Cloth, $4.50; leather. $5.5 0. 

Erichsen's Science and Art oi Surgery.— Eighth Edition. 

The Science and. Art of Surgery ; Being a Treatise on Surgical Injuries, 
Diseases and Operations. By John E. Erichsen, F. R. S., F. R. C.S., Professor of Sur- 
gery in University College, London, etc. From the eighth and enlarged English edition. 
In two large 8vo. vols, of 2316 pp., with 984 engravings on wood. Cloth, $9; leather, $11. 

Bryant's Practice of Surgery.— Fourth Edition. 

The Practice of Surgery. By Thomas Bryant, F. R. C. S., Surgeon and 
Lecturer on Surgery at Gay's Hospital, London. Fourth American from the fourth and 
revised English edition. In one large and very handsome imperial octavo volume of 1040 
with 727 illustrations. Cloth, $6.50; leather, $7.50. 

I of 589 pages. Cloth, $2.00. See Students' Series 

I of Manuals, page 30. 

I MILLER'S PRACTICE OF SURGERY. Fourth 

and revised American edition. In one large 8vo. 

vol. of 682 pp.. with 364 illustrations. Cloth, $3.75. 

MILLER'S PRINCIPLES OF SURGERY. Fourth 

American from the third Edinburgh ed. In one 

8vo. vol. of 638 pages, with 340 illus. Cloth, $3.75. 

PIRRIE'S PRINCIPLES AND PRACTICE OF 

SURGERY. Edited by John Neill, M. D. In 

one 8vo. vol. of 784 pp. with 316 illus. Cloth, $3.75. 

GANT'S STUDENT'S SURGERY. By Frederick 

James Gant, F. R. C. S. Square octavo, 848 pages, 

159 engravings. Cloth, $3.75. 

! HOLMES' SYSTEM OF SURGERY. THEORET- 
ICAL AND PRACTICAL. By Various Authors. 
Edited by Timothy Holmes, M. A. American edi- 
tion, revised and re-edited by John H. Packard, 

j M. D. Three large octavo volumes, 3137 pages, 
979 illustrations on wood and 13 lithographic 
plates. Per set, cloth, $18.00; leather, $21.00. 
Subscription only. 



DRUITT'S MANUAL OF MODERN SURGERY. 
Twelfth edition, thoroughly revised by Stanley 
Boyd, M. B 8vo. 965 pages, with 373 illustrations. 
Cloth, $4.00; leather,' $5.00. 

HOLMES' TREATISE ON SURGERY; ITS PRIN- 
CIPLES AND PRACTICE. From the fifth 
English edition, edited by T. Pickering Pick, 
F. R. C.S. In one octavo volume of 997 pages, 
with 428 illustrations. Cloth, $6.< ; leather, $7.00. 

MARSH ON THE JOINTS. In one 12mo. volume 
of 468 pages, with 64 woodcuts and a colored 
plate. Cloth, $2.00. See S'.riesof Clin>cal Manuals, 
page 30. 

BUTLIN ON DISEASES OF THE TONGUE. By 
Henry T. Butlin, F. R. C.S., Assistant Surgeon 
to St. Bartholomew's Hospital, London. In one 
12mo. volume of 456 pages, with 8 colored plates 
and 3 woodcuts. Cloth, $3.50. See Series of Clin- 
ical Manuals page 30. 

GOULD'S ELEMENTS OF SURGICAL DIAG- 
NOSIS. By A. Pearce Gould, M. S., M. B., 
F. R. C. S., Assistant Surgeon to Middlesex Hos 
pital, London. In one pocket-size 12mo. volume 



Lea Brothers & Co., Publishers. 706, 708 & 710 Sansom Street Philadelphia. 



Surgery — (Continued). 21 

Wharton's Minor Surgery and Bandaging.— Second Edition. 

Minor Surgery and Bandaging. By Henry E. Wharton, M. D., 
Demonstrator of Surgery in the University of Pennsylvania. In one 12mo. volume of 
529 pages, with 416 engravings, many being photographic. Cloth, $3.00. 

The book is one of the very best treatises on ! localities of the body. The author has thoroughly 
minor surgery and it ought to be adopted as a revised that portion of the work relating to the 
text book on "the subjects of which it treats. It aseptic and antiseptic methods of wound treat- 
contains more practical surgery within its limits ment, than which there is no more important 
and boundaries than any book of its kind we have subject in the whole domain of surgery. Much 
ever seen. Its illustrations are to be specially new matter has been added, which brings it 
commended, particularly those that relate to abieastof the very latest knowledge on the sub- 
bandaging, most of which have been taken from jects of which it treats. — Buffalo Medical and Sur- 
photographs of applied bandages in the several gical Journal. 



Treves' System of Surgery.— Vol. I. Just Ready. 

A System of Surgery. In Contributions by twenty-five English Authors. 
Edited by Frederick Treves, F.E C.S , Surgeon to and Lecturer on Surgery at the Lon- 
don Hospital, Examiner in Surgery at the University of Cambridge. In two large octavo 
volumes. Vol. I., 1178 pages, with" 463 engravings, and 2 color* d plates Cloth, $8.00. 
Just Heady. Vol. II., Preparing. 

Treves' Operative Surgery.— Two Volumes. 

A Manual of Operative Surgery. By Frederick Treves, F. E. C. S., 
Surgeon and Lecturer on Anatomy at the London Hospital. In two octavo volumes 
containing 1550 pages, with 422 engravings. Complete work, cloth, $9.00; leather, $11.00. 



We have no hesitation in declaring it the best 
work on the subject in the English language, and 
indeed, in many respects, the best in any lan- 
guage. It cannot fail to be of the greatest use 
both to practical surgeons and to those general 
practitioners who, owing to their isolation or to 
other ciroumstances, are forced to do much of 
their own operative work. We feel called upon 
to recommend the book so strongly for the 



excellent judgment displayed in the arduous task 
of selecting from among the thousands of vary- 
ingprocedures those most worthy of description ; 
for the way in which the still more difficult task 
of choosing among the best of those ha3 been 
accomplished; and for the simple, clear, 
straightforward manner in which the information 
thus gathered from all surgical literature ha3 
been conveyed to the reader. — Annals of Surgery. 



Treves' Student's Handbook of Surgical Operations. In one 

square 12mo. volume of 508 pages, with 94 illustrations. Cloth, $2.50. 

A Manual of Surgery. In Treatises by Various Authors, edited by Fred- 
erick Treves, F. R. C. S. in three 12mo. volumes, containing 1866 pages, with 213 
engravings. Price per set, cloth, $6.00. See Students' Series of Manuals, page 30. 

Treves on Intestinal Obstruction. In one 12mo. volume of 522 pages, 
with 60 ill us. Limp cloth, blue edges, $2.00. See Series of Clinical Manuals, page 30. 

Smith's Operative Surgery.— Revised Edition. 

The Principles and Practice of Operative Surgery. By Stephen 
Smith, M. D., Professor of Clinical Surgery in the University of the City of New York. 
Second and thoroughly revised edition. In one very handsome octavo volume of 892 
pages, with 1005 illustrations. Cloth, $4.00; leather, $5.00. 



This excellent and very valuable book is one of 
the most satisfactory works on modern operative 
surgery yet published. The book is a compendium 
for the modern surgeon. The present edition is 
much enlarged, and the text has been thoroughly 
revised, so as to give the most improved methods 
in aseptic surgery, and the latest instruments 
known for operative work. It can be truly said that 
as a handbook for the student, a companion for the 



surgeon, and even as a book of reference for the 
physician not especially engaged in the practice 
of surgery, this volume will long hold a most 
conspicuous place, and seldom will its readers, no 
matter how unusual the subject, consult its pages 
in vain. Its compact form, excellent print, num- 
erous illustrations, and especially its decidedly 
practical character, all combine to commend it.— 
Boston Medical and Surgical Journal. 



Ball on the Rectum and Anus.— New Edition. 

The Rectum and Anus, Their Diseases and Treatment. By 
Charles B. Bael, F. E. C. S., University Examiner in Surgery, Dublin. Second edi- 
tian. In one 12mo. volume of 453 pages, with 60 engravings and 4 colored plates. 
Cloth, $2.25. Just ready. See Series of Clinical Manuals, p. 30. 

Cheyne on Wounds, Dicers and Abscesses.— Just Ready. 

The Treatment of Wounds, Ulcers and Abscesses. By W.Watson 
Cheyne, M. B., F. K. S., F. B. C. S , Professor of Surgery in King's College, London. In 
one 12mo. volume of 207 pages. Cloth, $1.25. 

PICK ON FRACTURES AND DISLOCATIONS. 1 Limp cloth, $2.00. See Series of Clinical Manuals, 
In one 12mo. vol. of 530 pp., with 93 illustrations. | page 30. 



Lea Brothers & Co., Publishers, 70S, 708 & 710 Sansom Street, Philadelphia. 



22 Surgery— (Continued), Fractures, Dislocations. 

Vols I. and II. Just Ready. Vol. ill. Shortly. Vol. IV. Preparing. 

A SYSTEM OF SURGERY. 

BY AMERICAN AUTHORS. 

Edited by Fkedeejc S. Dennis, M.D., Professor of the Principles and Practice 
of Surgery, Believue Hospital Medical College, New York; President of the American 
Surgical Association, etc. Assisted by John S. Bileings, M.D., LL.D, D.C.L., Deputy 
Surgeon-General, U. S. A. In four imperial octavo volumes of about 900 pages each, 
proiusely illustrated in black and colors. Price per volume, cloth, $6 ; leather, $7 ; half 
Morocco, gilt back and top, $8.50. For sale by subscription only. Address the Publishers. 



Robert Abbe, M.D , 
Oorham Bacon, M.D. 
Herman M. Biggs, M.D., 
John S. Billings, M.D., 
William T. Bull, M.D., 
William H. Carmalt, M.D., 
Henry C. Coe, M.D., 
P. S. Conner. M.D., 
William T. Councilman, M.D., 
D. Brtson Delavan, M.D., 
Frederic S Dennis, M D., 
Edward K. Dunham, M.D , 
William H. For wood. M.D., 
G-eorge R. Fowler, M. D. , 
Frederick H. Gerrish, M.D., 
Arpad G. Gerster, M. L>., 

There really is now no complete work in English 
which can be considered as the rival of this. That 
the editor has selected his collaborators judiciously 
will be conceded when the names are read over. 
Each one of them is a teacher of surgery or a 
director of some large clinic, and each is, there- 
fore, prepared to speak from an extended expe- 
rience as well as from extensive study. The three 



LIST OF CONTRIBUTORS 

Virgil P. Gibnet, M.D., 
William A. Hardawat. M.D., 
Frank T. Hartley, M.D., 
Joseph Taber Johnson, M.D., 
William W. Keen, M.D., 
William T. Lusk, M.D., 
Charles McBurney, M.D , 
Rudolph Matas, M.D., 
Henry H. Mudd, M.D., 
Charles B. Nancrede, M.D., 
Henry D. Noyes, M. D, 
Roswell Patsk, M.D , 
Willard Parker, M.D., 
Lewis S. Pilcher, M.D., 
William H. Polk, M.D., 



Charles H. Porter, M.D., 
Maurice H. Richardson, M.D., 
John B. Roberts, M.D., 
George E. de Schweinitz, M.D., 
Nicholas Senn, M.D., 
Stephen Smith, M.D., 
Lewis A. Stimson, M.D., 
Robert W. Taylor, M.D., 
Louis McL. Tiffany, M.D., 
J. Collins Warren, M.D., 
Henry R. Wharton, M.D., 
Robert F. Weir, M.D., 
William H. Welch, M.D., 
J. William White, M.D., 
Horatio C. Wood, M.D., 



volumes which are to succeed this are to be as 
replete with information and as abreast of the 
times as this one already furnished. The editors, 
the publishers and the profession at large may be 
warmly congratulated, and we may feel that a 
long felt want for some such general treatise has 
at last been supplied. — American Journal of the 
Medical Sciences, June, 1895. 



Stimson's Operative Surgery.— New (3d) Edition, Just Ready. 

A Manual of Operative Surgery. By Lewis A. Stimson, B. A ., M D., 
Professor of Clinical Surgery in the University of the City of New York. New (3d) 
edition. In one royal 12mo. volume of 614 pages, with 306 illustrations. Cloth, $3.75. 

The demand for a third edition of Professor Stimson's excellent Marmal of Operative 
Surgery attests the service it has rendered to thousands of physicians and surgeons. The 
author has utilized this opportunity to place the work fully abreast of the most advanced 
surgery. The profuse series of illustrations has been largely re-engraved and additions have 
been made to it wherever clearness and fulness of instruction could be promoted thereby. As 
surgery is chiefly operative, an authoritative volume on its procedures is an indispensable part 
of the equipment of every surgeon and likewise of every physician in general practice. 

Hamilton on Fractures and Dislocations.— Eighth Edition. 

A Practical Treatise on Fractures and Dislocations. By Frank 
H. Hamilton, M. D., LL.D., Surgeon to Believue Hospital, New York. New (8th) edi- 
tion, revised and edited by Stephen Smith, M. D. , Prof, of Clinical Surgery in Univ. of 
City of N. Y. In one octavo volume of 832 pp., with 507 illus. Cloth, $5.50 ; leather, $6.50. 
Its numerous editions are convincing proof if any jeet of such magnitude is no easy one. Dr. Smith 



Its numerous editions are convincing proof it any 
is needed, of its value and popularity. It is pre 
eminently the authority on fractures and disloca- 
tions, and universally quoted as such. In the new 
edition it has lost none of its former worth. The 
additions it has received by its recent revision make 
it a work thoroughly in accordance with modern 

Practice, theoretically, mechanica'ly, aseptically. 
'he task of writing a complete treatise on a sub- 



ject of such magnitude is no easy 
has aimed to make the present volume a correct 
exponent of our knowledge of this department 
of surgery. The more one reads the more 
one is impressed with its completeness. The work 
has been accomplished, and has been done clearly, 
concisely, excellently well.— .Boston Medical and 
Surgical Journal. 



Stimson on Fractures and Dislocations. 

A Treatise on Fractures and Dislocations. By Lewis A. Stimson, 
M.D. In two handsome octavo volumes. Vol. I., Fractures, 582 pages, 360 illustra- 
tions. Vol. II., Dislocations, 540 pages, with 163 illustrations. Complete work, 
cloth, $5.50 ; leather, $7.50. Either volume separately, cloth, $3.00 ■ leather, $4.00. 

The appearance of the second volume marks the 
completion of the author's original plan of prepar- 
ing a work which should present in the fullest 
manner all that is known on the cognate subjects 
of Fractures and Dislocations. The volume on 
Fractures assumed at once the position of authority 
on the subject, and its companion on Dislocations 
will no doubt be similarly received. This volume 



exhibits the surgery of Dislocations as it is taught 
and practised by the most eminent surgeons of the 
present time. Containing the results of such ex- 
tended researches it must for a long time be re- 
garded as an authority on all subjects pertaining 
to dislocations. Every practitioner of surgery will 
feel it incumbent on him to have it for constant 
reference. — Cincinnati Medical News. 



Lea Brothers & Co., Publishers, 706, 708 & 710 Sansom Street, Philadelphia. 



Ophthalmology, 



23 



Norris & Oliver's Ophthalmology. 



A Text-Book of Ophthalmology. By William F. Norris, M. D., 
Professor of Ophthalmology in the University of Pennsylvania, and Charles A. Oliver, 
M. D., Surgeon to "Wills' Eye Hospital, Philadelphia. In one very handsome octavo 
vol. of 632 pages, with 357 engravings and 5 colored plates. Cloth, $5 ; leather, $6. 
This is the first text-book of diseases of the eye ! to any would-be competitor. Wonderfully cheap 



written by American authors for American col- 
legos and" students. Rules and procedures are 
made so plain and so evident that any student 
can easily understand and employ them. It is 
succinct in recital, practical in its teachings, judi- 
cious in the selection of material and conservative, 
yet radical when necessary. In treatment it can 
be accepted as from the voice and the pen of a 
respected and recognized authority. The illus- 
trations far outnumber those of its contempora- 
ries, whilst the high grade and unbiased opinions 
of the teachings serve to give it a rank superior 



in price, beautifully printed and exquisitely illus- 
trated, the mechanical make-up of the book is 
all that can be desired. After most conscientious 
and painstaking perusal of the work, we unre- 
servedly endorse it as the best, the safest and the 
most comprehensive volume upon the subject that 
has ever been offered to the American medical 
public. We sincerely hope that it may find its 
way into the list of text-books of every English- 
speaking college of medicine. — Annals of Ophthal- 
mology ayid Otology. 



Berry on the Eye.— New (2d) Edition. 

Diseases of the Eye. A Practical Treatise for Students of Ophthalmology. 
By George A. Berry, M.B., F. E. C. S., Ed., Ophthalmic Surgeon, Edinburgh Royal 
Infirmary. New (second) edition. In one octavo volume of 750 pages, with 197 illustra- 
tions, mostly lithographic. Cloth, $8.00. 



This is by far the best work upon its theme in 
the English language that we have seen, for the 
diction is pure and clear, and besides, the beauti- 
ful illustrations of normal and diseased conditions 
make it a valuable addition to the library of all 
practitioners, general as well as special. We have 
never seen more real delineation of disease, the 
coloring is perfect, and each illustration is an 



"object-lesson." We cannot but reiterate what we 
said at the beginning, that we have had great pleas- 
ure in the perusal of this work, and great profit, and 
that we consider it the best on the subject in the 
English language today, not only for its diction 
but for its instructive illustrations. — The American 
Journal of the Medical Sciences. 



Juler's Ophthalmic Science and Practice.— New (2d) Edition. 

A Handbook of Ophthalmic Science and Practice. By Henry E. 
Jtjler, F. K. C. S., Senior Assistant Surgeon, Royal Westminster Ophthalmic Hospital; 
Late Clinical Assistant, Moorfields, London. New (2d) edition. Handsome 870. volume 
of 561 pages, with 201 woodcuts, 17 colored plates, selections from Test-types of Jaeger 
and Snellen, and Holmgren's Color-blindness Test. Cloth, $5.50 ; leather, $6.50. 

The continuous approval manifested towards i matter of practical value. The sections devoted tb 
this work testifies to the success with which the treatment are singularly full, and at the same time 
author has produced concise descriptions and concise, and couched in language that cannot fail 
typical illustrations of all the important affections to be understood. — The Medical Age. 
of the eye. The volume is particularly rich in \ 

Nettleship on the Eye.— Fifth Edition. 

Diseases of the Eye. By Edward Nettleship, F. R. C. S., Ophthalmic 
Surgeon at St. Thomas' Hospital, London. Surgeon to the Royal London (Moorfields) 
Ophthalmic Hospital. Fourth American from the fifth English edition, thor- 
oughly revised. With a Supplement on the Detection of Color Blindness, by Wil- 
liam Thomson, M. D., Professor of Ophthalmology in the Jefferson Medical College 
Philadelphia. In one 12mo. volume of 500 pages, with 164 illustrations, selections from 
Snellen's test-types and formulae, and a colored plate. Cloth, $2.00. 



This is a well-known and a valuable work. It 
was primarily intended for the use of students, 
and supplies" their needs admirably, but it is as 
useful for the practitioner, or indeed more so. It 
does not presuppose the large amount of recondite 



knowledge to be present which seems to be as- 
sumed in some of our larger works, is not tedious 
from over- conciseness, and yet covers the more 
important parts of clinical ophthalmology. — New 
York Medical Journal. 



Carter & Frost's Ophthalmic Surgery. 

Ophthalmic Surgery. By R. Brudenell Carter, F.R. C. S., Lecturer on 
Ophthalmic Surgery at St. George's Hospital, London, and W. Adams Frost, F. R. C. S., 
Joint Lecturer on Ophthalmic Surgery at St. George's Hospital, London. In one 12mo. 
volume of 559 pages, with 91 woodcuts color-blindness test, test-types and dots and appen- 
dix of formulas. Cloth, $2.25. See Series of Clinical Manuals, page 30. 



THOMPSON ON THE URINARY ORGANS. 

Lectures on Diseases of the Urinary Organs. 

By Sir Henry Thompson, Professor of Clinical 

Surgerv in University College Hospital, London. 

Second American from the third English edition. 

Octavo, 203 pages, 25 illustrations Cloth, $2 25. 
THOMPSON ON THE PATHOLOGY AND 

TREATMENT OF STRICTURE OP THE 

URETHRA AND URINARY FISTULA. 

From the third English edition. In one octavo 

volume of 359 pages, with 47 engravings and 3 

plates. Cloth, $3.50. 
BASHAM UN RENAL DISEASES: A Clinical 

Guide to their Diagnosis and Treatment. 12mo. 
304 pages, with 21 illustrations. Cloth, $2.00. 



WELLS ON THE EYE. In one octavo volume. 

LAURENCE AND MOON'S HANDY BOOK OF 
OPHTHALMIC SURGERY, for the use of Prac- 
titioners. Second edition. In one octavo vol- 
ume of 227 pages, with 65 illus. Cloth, $2.75. 

LAWSON ON INJURIES TO THE EYE, ORBIT 
AND EYELIDS: Their Immediate and Remote 
Effects. In one octavo volume of 404 pages, with 
92 illustrations ninth, £3.50 

MORRIS ON SURGICAL DISEASES OF THE 
KIDNEY. By Henry Morris, F. R, C. S., Surgeon 
to Middlesex Hospital, London. 12mo., 554 pp., 
with 40 woodcuts, and 6 colored plates. Limp 
cloth, $2.25. See Series of Clinical Manuals, p. 30. 



Lea Brothers & Co., Publishers, 706, 708 & 710 Sansom Street, Philadelphia. 



24 Otology, Urinary & Renal Dis., Dentistry, 



Politzer on Diseases of the Ear.— Third Edition. 

A Text-Book of Diseases of the Ear and Adjacent Organs. 
By Dr. Adam Politzer, fmperial-Boyal Professor of Aural Therapeutics in the Univer- 
sity of Vienna, Chief of the Imperial -Koyal University Clinic for Diseases of the Ear in 
the General Hospital, Vienna. Translated into English from the third ai d revised 
German edition by Oscar Dodd, M. D., Clinical Instructor in Diseases of the Eye and 
Ear, College of Physicians and Surgeons, Chicago. Edited by Sir William Dalby, 
F. R. C. S., M. B., Consulting Aural Surgeon to St. George's Hospital, London. In one 
large octavo volume of 748 pages, with 330 illustrations. Cloth, $5.50. 

underlie the clinical remarks and details of meth- 
ods of treatment. The indications for treatment 
are clear and reliable. We can confidently rec- 
ommend it, for it contains, as stated by the editor 
in his preface, all that is known upon the subject. 
— London Lancet. 



This edition of the eminent Vienna professor's 
well-known work will be welcomed by those who 
wish to obtain a complete account of all that is 
known in connection with aural diseases. Who- 
ever peruses it carefully cannot fail to be struck 
with the details, the extensive references, and 
especially the valuable pathological data, which 



Field's Manual of Diseases of the Ear. Fourth Edition. 

A Manual of Diseases of the Ear. By George P. Field, M. E 4 C. S., 
Aural Surgeon and Lecturer on Aural Surgery in St Mary's Hospital Medical School, 
London. In one octavo of 39 1 pp., with 73 engravings and 2 1 colored plates. Cloth, $3.75. 
To those who desire a concise work on diseases large class of cases of ear disease that comes 
of the ear, clear and practical, this manual com- properly within his province. The illustrations 
mends itself in the highest degree. It is just such are apt and well executed while the make-up of 
a work as is needed by every general practi- the work is beyond criticism. — The American 
turner to enable him to treat intelligently the Practitioner and Neivs. 

Burnett on the Ear.— Second Edition. 

The Ear, Its Anatomy, Physiology and Diseases. A Practical 
Treatise for the use of Medical Students and Practitioners. By Charles H. Burnett, 
A. M., M. D., Professor of Otology in the Philadelphia Polyclinic ; President of the 
American Otological Society. Second edition. In one handsome octavo volume of 580 
pages, with 107 illustrations. Cloth, $4.00 ; leather, $5.00. 

Black on the Urine.— Just Ready. 

The Urine in Health and Disease, and Urinary Analysis, Physi- 
ologically and Pathologically Considered. By D. Campbell Black, M. D., 
*L.Pv. C. S., Professor of Physiology, Anderson College Medical School. In one 12mo. 
volume of 256 pages, with 73 engravings. Cloth, $2.75. 

Roberts on Urinary and Renal Diseases.— Fourth Edition. 

A Practical Treatise on Urinary and Renal Diseases, including 
Urinary Deposits. By Sir William Eoberts, M. D., Lecturer on Medicine in the 
Manchester School of Medicine, etc. Fourth American from the fourth London edi- 
tion. In one handsome octavo volume of 609 pages, with 81 illustrations. Cloth, $3.50. 

Purdy on Bright's Disease and Allied Affections. 

Bright's Disease and Allied Affections of the Kidneys. By 

Charles W. Purdy, M. D., Professor of Genito-Urinary and Eenal Diseases in the Chi- 
cago Polyclinic. In one octavo vol. of 288 pages, with illustrations. Cloth, $2.00. 

The American Text-Books of Dentistry.— Preparing. 

In Contributions by Various Authors. In two octavo volumes of about 
600 pages each, fully illustrated. Volume I., Operative Dentistry. Edited by 
Edward C. Kirk, D. D. S., Lecturer on Operative Dentistry, Dept. of Dentistry, Univ. of 
Penna. Volume IE., Mechanical Denttstry. Edited by Charles J. Essig, M. D., 
D. D. S , Prof, of Mechanical Dentistry and Metallurgy, Dept. of Dentistry, Univ. of Penna. 

The American System of Dentistry. Volume IV. Preparing. 

In Treatises by Various Authors. Edited by Wilbur F. Litch, M. D., 
D. D. S., Professor of Prosthetic Dentistry, Materia Medica and Therapeutics in the 
Pennsylvania College of Dental Surgery. In four very handsome octavo volumes con- 
taining over 4000 pages, with about 2400 illustrations and many full-page plates. Per 
volume, cloth, $6 ; leather, $7 ; half Morocco, gilt top, $8. For sale by subscription only. 

As an encyclopedia of Dentistry it has no su- I doubtless it is), to mark an epoch in the history of 
perior. It should form a part of every dentist's j dentistry. Dentists will be satisfied with it and 
library, as the information it contains is of the | proud of it — they must. It is sure to be precisely 

freatest value to all engaged in the practice of what the student needs to put him and keep him 
entistry. — American Journal of Dental Sciencf. j in the right track, while the profession at large 
A grand system, big enough and good enough | will receive incalculable benefit from it.— Odonto- 
and handsome enough for a monument (which | graphic Journal. 



COLEMAN'S MANUAL OF DENTAL SURGERY 
AND PATHOLO&Y. By Alfred Coleman, L.D.S. 
Thoroughly revised and adapted to the use of 



American Students, by Thomas C. Stellwagen, 
D. D.S. Octavo, 412 pages, with 331 illustrations. 
Cloth, $3.25. 



Lea Brothers & Co., Publishers, 706, 708 & 710 Sansom Street, Philadelphia. 



Impotence, Sterility, Venereal, Skin. 25 

Taylor on Venereal Diseases.— Sixth Edition. Just Ready. 

The Pathology and Treatment of Venereal Diseases. By Kobert 
W. Taylof, A.M., M.D., Clinical Professor of Genito-Urinary Diseases in the College 
of Physicians and Surgeons, New York. Sixth editioD. In one very handsome octavo 
volume of lOi 2 pages, with 230 engravings and 7 colored plates. Cloth, $5.50; leather, 
$6.50. 

The perennial prevalence of the Yenereal Diseases, and their power to invade all tissues 
of the body and consequently to modify all other human maladies, unite to render a working 
knowledge of this subject essential to every physician, surgeon and specialist. The writer of 
this book has lone enjoyed a position of preeminent authority. Since the exhaustion of the 
fifth edition of Bumstead c0 Taylor on Venereal Diseases, Dr. Taylor has been assiduously 
engaged in sifting the results of the immense activity directed towards this subject in recent 
years, and in the present volume he places at the command of the profession a body of 
knowledge, complete, clear, modern and authoritative, a work new both in text and illustra- 
tions. It is assured of the foremost position as a test-book and work of reference. 

Fuller on Male Sexual Disorders.— Just Ready. 

Disorders of the Sexual Organs in the Male. By Eugene Fuller, 
M.D., Instructor in Yenere.il and Genito-Urinary Diseases, New York Post-Graduate 
Medical School. In one very handsome octavo volume of 238 pages, with 25 engravings 
and 8 fuli-page.l plates. Cloth, 12.00. 

Extensive experience in private practice and in one of the leading New York medical 
schools has convinced the author that male sexual disorders arise more frequently from 
pathological states of the organs themselves than from neurological or mental causes. He has 
endeavored in this work to place the literature of sexual pathology abreast of that on sexual 
neurology and to furnish the profession with a guide to diagnosis and treatment in which 
all the etiological factors are considered according to their relative importance. The rich 
rewards obtained by charlatans practising in this branch of medicine may be considered in a 
certain sense as an expression of public opinion upon the comparative success of the regular 
practitioner. Rational methods must rescue this most important class of disease from the 
empirics, and a work pointing the way to successful treatment founded upon sound pathology 
and diagnosis will benefit the profession almost as much as their patients. 

Gross on Impotence, Sterility, etc.— Fourth Edition. 

A Practical Treatise on Impotence, Sterility, and Allied Dis- 
orders of the Male Sexual Organs. By Samuel W. Gross, A. M., M. D.> 
LL. D., Prof, of Surgery in the Jefferson Med. Coll. of Phila. Fourth edition, thoroughly 
revised by F. R. Sturgis, M.D., Prof, of Dis. of the Genito-Urinary Organs and of Venereal 
Dis., N. Y. Post Grad. Med. School. In one 8vo. vol. of 165 pp., with 18 illus. CI., $1.50, 

Culver & Hayden's Manual of Venereal Diseases. 

A Manual of Venereal Diseases. By Everett M. Culver, M. D., 
Pathologist and Assistant Attending Surgeon, Manhattan Hospital, New York, and James 
K. Hayden, M. D., Chief of Clinic Venereal Department, College of Physicians and Sur- 
geons, New York. In one 12mo. volume of 289 pages, with 33 illus. Cloth, $1.75. 

This bock is a practical treatise, presenting in a venereal diseases for the general practitioner to 
condensed form the essential features of our pres- adopt as a guide. The general practitioner needs 
ent knowledge of the three venereal diseases, a few simple, concise and clearly presented laws, 
syphilis, chancroid and gonorrhea. We have ex- in the execution of which he cannot fail either to 
amined this work carefully and have come to the cure or prevent the ravages of the maladies in 
conclusion that it is the most concise, direct and question and their direful results.— Buffalo Medical 
able treatise that has appeared on the subject of and Surgical Journal. 



Cornil on Syphilis. 

Syphilis, its Morbid Anatomy, Diagnosis and Treatment. By V. 
Cornil, M.D. Specially revised by the Author, and translated with notes and additions 
by J. Henry C. Simes, M. D., and J. William White, M.D. Octavo 461 pages, with 
84 illustrations. Cloth, $3.75. 

Hardaway's Manual ol Skin Diseases. 

Manual of Skin Diseases. With Special Keferenceto Diagnosis and Treat- 
ment. For the u^e of Students and General Practitioners. By W. A. Haedaway, M. D., 
Professor of Skin Diseases in the Missouri Medical College. 12mo., 440 pp. Cloth, $3.00. 



GROSS' PRACTICAL TREATISE ON THE DIS- 
EASES, INJURES AND MALFORMATIONS 
OF THE URINARY BLADDER, THE PROS- 
TATE GLAND AND THE URETHRA. By 
Samuel D. Gross, M.D., LL.D., D.C.L., etc. Third 
edition, thoroughly revised by Samuel W. Gross, 
M.D. In one octavo volume of 574 pages, with 
170 illustrations. Cloth, $4.50. 



volume of 542 pages, with 9 chromo-lithographs. 

Cloth, $2.25. See Seiies of Clinical Manuals, 

page 30. 
HILL ON SYPHILIS AND LOCAL CONTAGIOUS 

DISORDERS. In one 8vo vol. of 479 p. Cloth, $3.25. 
LEE'S LECTURES ON SYPHILIS AND SOME 

FORMS OF LOCAL DISEASE AFFECTING 

THE ORGANS OF GENERATION. In one 



HUTCHINSON ON SYPHILIS. In one 12mo. 8vo. volume of 246 pages. Cloth, $2.25, 
Lea Brothers & Co., Publishers, 706, 708 & 710 Sansom Street, Philadelphia. 



26 



Venereal and Skin Diseases, 



Hyde on the Skin.— Third Edition. 



A Practical Treatise on Diseases of the Skin. For the use of Students 
and Practitioners. By J. Nevins Hyde, A. M., M. D., Professor of Dermatology and Ven- 
ereal Diseases in Kush Medical College, Chicago. Third edition. In one octavo volume 
of 802 pages, with 9 colored plates and 108 engravings. Cloth, $5.00 ; leather, $6.00. 



The third edition, just issued, fulfils all the ex- 
pectations warranted by the great accumulation 
of dermatological material since the earlier 
editions were brought out, and puts this work at 
the head of the modern American treatises on 
skin diseases. The author has introduced thirty- 
five new diseases in this edition. He is especially 
to be congratulated on his chapter on tuberculosis. 
Five plates and twenty two woodcuts, all of great 
excellence, have been added to the illustrations. 
The excellence of the chapters on treatment, to- 
gether with the care that has been bestowed on 
subjects that have acquired new interest, make 
the book one to be warmly recommended. — Bus- 
ton Medical and Surgi<al Journal. 

The qualities that have contributed so much to 
its previous popularity still remain. The chief of 
these unquestionably are the standpoint of prac- 
tical medicine from which it speaks and its wealth 
of therapeutical information. The writer knows 
no book in which one can seek more satisfactorily 



for information as to how to manage his patients 
with skin diseases. The present edition may be 
commended as being an exposition of the subject 
fully up to the present state of our knowledge. 
— The Chicaqo Clinical Review. 

Dr. Hyde's book may be heartily commended 
to the student and practitioner alike as one of the 
best exponents of the subject now before the pro- 
fession. — The American Journal of the Medical 
Sciences. 

Dr. Hyde is an experienced scholar as well as a 
competent author, and his former editions were 
received with approval by dermatologists as well 
as by those general practitioners who are inter- 
j ested in the study and treatment of diseases of 
the skin. The treatise is one that affords much 
satisfaction in that it is a sale guide for both stu- 
dents and practitioners, either general or special, 
and particularly does it adapt itself to the use of 
dermatologists. — Buffalo Medical and Surgical Jour- 
nal. 



Taylor's Clinical Atlas of Venereal and Skin Diseases. 

A Clinical Atlas of Venereal and Skin Diseases: Including Diag- 
nosis, Prognosis and Treatment. By Eobert W. Taylor, A. M., M. D., Clinical Pro- 
fessor of Genito- Urinary Diseases in the College of Physicians and Surgeons, New York; 
In eight large folio parts, and comprising 58 beautifully colored plates with 213 figures, 
and 431 pages of text with 85 engravings. Price per part, $2.50. Bound in one volume, 
half Russia, §27 ; half Turkey Morocco, $28. For sale by subscription only. Specimen 
plates sent on receipt of 10 cents. A full prospectus sent to any address on application. 

Jackson's Ready-Reference Handbook of Skin Diseases. 

The Ready-Reference Handbook of Diseases of the Skin. By 

George Thomas Jackson, M. D., Professor of Dermatology, Woman's Medical College 
of the New York Infirmary. In one 12mo. volume of 544 pages, with 50 illustrations 
and a colored plate. Cloth, $2.75. 

Morris on the Skin. 

Diseases of the Skin. An Outline of the Principles and Practice of Der- 
matologv. By Malcolm Morris, F. R. C. S , Surgeon to the Skin Department, St. Mary's 
Hospital, London, in one square octavo volume of 565 pages, with 19 chromo-lithographic 
figures and 17 engravings. Cloth, $3.50. 

The present work is entirely new and is I pla^e within the intelligent command of the 
designed to be es.-entially clinical and practical reader the very full recommendations as to 
in scope. Diagnosis, symptoms, causation and treatment. Every part of the book represents the 
prognosis receive sufficient space to convey a most modern knowledge and methods — Pacific 
clear idea of the nature of each disease, and to Medical Journal. 



Pye-Smith on Diseases of the Skin. 

A Handbook of Diseases of the Skin. By P. H. Pye-Smith, M. D., 
F. K. S , Physician to Guy's Hospital, London. In one octavo volume of 407 pages, 
with 26 illustrations, 23 of which are colored. Cloth, $2.00. 

The book is an excellent one, and we commend j known as one of the eminent physicians to Guy's 
it to all interested in the subject. It is written by ! Hospital, and we have no hesitation in saying 
one entirely familiar with skin diseases, both '[ that he has written an original and valuable 
from the standpoint of the specialist and the j handbook oa skin diseases, sound and practical 
general practitioner. Dr. Pye-Smith is favorably | in all its bearings. — International Med. Magazine. 



Jamieson on Diseases of the Skin.— Third Edition. 

Diseases of the Skin. A Manual for Students and Practitioners. By 
W. Allan Jamieson, M. D., Lecturer on Diseases of the Skin, School of Medicine, Edin- 
burgh. Third edition, revised and enlarged. In one octavo volume of 656 pages, with 
woodcut and 9 double-page chromo lithographic illustrations. Cloth, $6.00. 

The scope of the work is essentially clinical, lit- 
tle reference being made to pathology or disputed 
theories. Almost every subject is followed by 



illustrative cases. The pages are filled with inter- 
est to all thosp occupied with skin diseases. The 



general practitioner will find the book of great 
value in matters of diagnosis and treatment. The 
latter is quite up to date, and the formulae have 
been selected with care. — Medical Record. 



HILLIER'S HANDBOOK OF SKIN DISEASES; 
for Students and Practitioners. Second Ameri- 
can edition. In one 12mo. volume of 353 pages, 
with plates. Cloth, %i 25. 



WILSON'S S TUDENT'S BOOK OF CUTANEOUS 
MEDICINE AND DISEASES OF THE SKIN. 
In one handsome small octavo volume of 535 
pages. Cloth, $3.50. 



Lea Brothers & Co., Publishers, 70S, 708 & 710 Sansom Street, Philadelphia. 



Diseases of Women, 



27 



The American Systems of Gynecology and Obstetrics. 

Systems of Gynecology and Obstetrics, in Treatises by American 
Authors. Gynecology edited by Matthew D. Mann, A. M., M. D., Professor of Obstetrics 
and Gynecology in the Medical Department of the University of Buffalo; and Obstet- 
rics edited by Barton Cooke Hirst, M. D., Associate Professor of Obstetrics in the 
University of Pennsylvania, Philadelphia. In four very handsome octavo volumes, con- 
taining 3612 pages, 1092 engravings and 8 plates. Complete Avork now ready. Per vol- 
ume: Cloth, $5.00; leather, $6.00; half Russia, $7.00. For sale by subscription only. 
Address the Publishers. Full descriptive circular free on application. 

In our notice of the "System of Practical Medi- j It, like the other, has been written exclusively 
cine by American Authors," we made the follow- by American physicians who are acquainted with 



ing statement; — "It is a work of which the pro- 
fession in this country can feel proud. Written 
exclusively by American physicians who are ac- 
quainted with all the varieties of climate in the 
United States, the character of the soil, the man- 
ners and customs of the people, etc., it is pecul- 
iarly adapted to the wants of American practition- 
ers of medicine, and it seems to us that every one 
of them would desire to have it." Every word 
thus expressed in regard to the "American Sys- 
tem of Practical Medicine" is applicable to the 
"System of Gynecology by American Authors." 



all the characteristics of American people, who are 
well informed in regard to the peculiarities of 
American women, their manners, customs, modes 
of living, etc. As every practising physician is 
called upon to treat diseases of females, and as 
they constitute a class to which the family phy- 
sician must give attention, and cannot pass over 
to a specialist, we do not know of a work in any 
department of medicine that we should so strongly 
recommend medical men generally purchasing.— 
Cincinnati Med. News. 



Emmet's Gynaecology.— Third Edition. 



The Principles and Practice of Gynecology ; For the use of Students 
and Practitioners of Medicine. By Thomas Addis Emmet, M. D., LL. D., Surgeon to 
the Woman's Hospital, New York, etc. Third edition, thoroughly revised. In one 
large and very handsome 8vo. vol. of 880 pp., with 150 illus. Cloth, $5; leather, $6. 

the privilege thus offered them of perusing the 
views and practice of the author. His earnestness 



We are in doubt whether to congratulate the 
author more than the profession upon the appear- 
ance of the third edition of this well-known work. 
Embodying, as it does, the life-long experience of 
one who has conspicuously distinguished himself 
as a bold and successful operator, and who has 
devoted so much attention* to the specialty, we 
feel sure the profession will not fail to appreciate 



of purpose and conscientiousness are manifest. 
He gives not only his individual experience but 
endeavors to represent the actual state of gynae- 
cological science and art. — British Medical Jour- 
nal. 



Tait's Diseases of Women and Abdominal Surgery. 

Diseases of Women and Abdominal Surgery. By Lawson Tait 7 
F. E. C. S., Professor of Gynaecology in Queen's College, Birmingham, late President of 
the British Gynecological Society, Fellow American Gynaecological Society. In two 
octavo vols. Vol. L, 554 pp., 62 engravings and 3 plates. Cloth, $3. Vol, II., preparing. 
Mr. Tait never writes anything that, does not | on the technique of surgical operation 



command attenti-- n by reason of the originality of 
his ideas and the clear and forcible manner in 
which they are expressed. This is eminently 
true of tne present work. Germs of truth are 
thickly scattered throughout; single happily 
worded sentences express what another author 
would have expanded into pages. Useful hints 



ingenious 
theories on pathology, daring innovations en long- 
established lines — these succeed one another 
with a bewildering rapidity. His position has 
long been assured We cannot repress our admi- 
ration for the restless genius of the great sur- 
geoa. — American Journal of the Medical Sciences. 



Edis on Diseases of Women. 

_ The Diseases Of Women. Including their Pathology, Causation, Symptoms, 
Diagnosis and Treatment. A Manual for Students and Practitioners. By Arthur W. 
Edis, M. D., Lond., F. E. C. P., M. E.G. S., Assistant Obstetric Physician to Middlesex 
Hospital, late Physician to British Lying-in-Hospital, In one handsome octavo volume 
of 576 pages, with 148 illustrations. Cloth, $3.00 ; leather, $4.00. 

among the more common methods of treat- 
ment, and yet very little is said about them in 
many of the text-books. The book is one to be 
warmly recommended especially to students and 
general practitioners, who need a concise but com- 
plete resume of the whole subject. Specialists, too, 
will find many useful hints in its pages.— Boston 
Medical and Surgical Journal. 



The special qualities which are conspicuous 
are thoroughness in covering the whole ground, 
clearness of description and conciseness of state- 
ment. Another marked feature of the book is 
the attention paid to the details of many minor 
surgical operations and procedures, as, for 
instance, the use of tents, application of leeches, 
and use of hot water injections. These are 



Duncan on Diseases of Women. 

Clinical Lectures on the Diseases of Women; Delivered in Saint 
Bartholomew's Hospital. By J. Matthews Duncan, M. D., LL. D., F. E, S. E., etc. 
In one octavo volume of 175 pages. Cloth, $1.50. 



HODGE ON DISEASES PECULIAR TO WOMEN. 
Including Displacements of the Uterus. Second 
edition, revised and enlarged. In one beauti- 
fully printed octavo volume of 519 pages, with 
original illustrations. Cloth, $4.£0. 



WEST'S LECTURES ON THE DISEASES OF 
WOMEN Third American from the third Lon- 
don edition. In one octavo volume of 543 pages. 
Cloth, $3.75; leather, §4.75. 



Lea Brothers & Co., Publishers, 706, 708 & 710 Sansom Street Philadelphia. 



28 



Diseases of Women — (Continued). 



Thomas & Munde on Diseases o! Women.— Sixth Edition. 

A Practical Treatise on the Diseases of "Women. By T. Gaillard 
Thomas, M. D., LL. D., Emeritus Professor of Diseases of Women in the College of 
Physicians and Surgeons, New York, and Paul F. Munde, M.D., Professor of Gynecol- 
ogy in the New York Polyclinic. Sixth edition, thoroughly revised and rewritten 
by Dr. Munde, In one large and handsome octavo volume of 824 pages, with 347 
illustrations, of which 201 are new. Cloth, $5.00 ; leather, $6.00. 

book we know, and will be of especial value to the 



The profession has sadly felt the want of a text- 
book on diseases of women, which should be com- 
prehensive and at the same time not diffuse, 
systematically arranged so as to be easily grasped 
by the student of limited experience, and which 
should embrace the wonderful advances which 



general practitioner as well as to the specialist. 
The illustrations are very satisfactory.— Boston 
Medical and Surgical Journal. 

This work, which has already gone through five 
large editions, and has been translated into 



have been made within the last two decades. French, German, Spanish and Italian, is too well 

Dr. Munde brings to his work a most practical known to require commendation. It continues to 

knowledge of the subjects of which he treats and be the most practical and at the same time the 

an exceptional acquaintance with the world's liter- most complete treatise upon the subject in print, 

ature of this important branch of medicine. The the changes that have been made only increasing 

result is what is, perhaps, on the whole, the best its value. — The Archives of Gynecology, Obstetrics 

practical treatise en the subject in the English and Pediatrics. 
language. It is, as we have said, the best text- 



Sutton on Tumors, Innocent and Malignant. 



Tumors, Innocent and Malignant. Their Clinical Features and Ap- 
propriate Treatment. By J. Bland Sutton, F. B. C. S., Assistant Surgeon to the Mid- 
dlesex Hospital, London. In one very handsome octavo volume of 526 pages, with 250 
engravings and 9 full page plates. Cloth, $4.50. 

many years of research upon a subject embracing 



Sutton has without doubt 'written the best 
general work on tumors which has yet appeared 
in the English language. We urge all of our 
readers to get this splendid book. — The St. Louis 
Medical and Surgical Journal. 

The author is widely known as one of the fom 



some of the commonest, most painful and hitherto 
hopeless of human affections. As this work deals 
exhaustively with tumors it will furnish the 
surgeon, gynecologist and general practitioner 
with indispensable aid in the early recognition 



most surgeons and pathologists of London. His ; and successful treatment of this class of disease. 



ability has already been recognized in his earlier 
works. In the present instance he has spent 



■The Omaha Clinic. 



Sutton on the Ovaries and Fallopian Tubes. 

Surgical Diseases of the Ovaries and Fallopian Tubes, including 
Tubal Pregnancy. By J. Bland Sutton, F. B. C. S., Assistant Surgeon to the 
Middlesex Hospital, London. In one square octavo volume of 514 pages, with 119 
engravings and 5 colored plates. Cloth, $3.00. 

is not for them alone ; the general practitioner 



This is not a book to be read and then shelved ; 
it is one to be studied. It is not based upon 
hypotheses but upon facts. It makes pathology 
practical, and inculcates a practice based upon 
pathology. It is succinct, yet thorough; practi- 
cal, yet scientific; conservative, yet bold It is 
probably on the table of all gynecologists; but it 



one : 
needs just such a book. It will be of immense 
service to him in the study of pelvic diseases, and 
will assuredly open his eyes to the progress made 
by conscientious, painstaking workers like Dr. 
Sutton in the fieid of pathology and differential 
diagnosis.— International Medical Magazine. 



Davenport's Non-Surgical Gynecology — Second Edition, 

Diseases of Women, a Manual of X3"on- Surgical Gynecology. 

Designed especially for the Use of Students and General Practitioners. By Francis 
H. Davenport, M. D., Assistant in Gynaecology in the Medical Department of Harvard 
University. Second edition. In one 12mo. vol. of 314 pages, with 107 illus. Cloth, $1.75. 

the actual test of experience, and being concisely 
and clearly written, conveys a great amount of in- 
formation in a convenient space. — Annals of Gynce- 



Many valuable volumes already exist on the 
surgical aspects of gynecology, but scant attention 
has been paid in recent years to the non-surgical 
treatment of women's diseases. The present 
volume, dealing with nothing which has not stood 



cology and Pcediatry. 



May's Manual of Diseases of Women.— Second Edition. 

A Manual of theDiseases of Women. Being a concise and systematic 
exposition of the theory and practice of gynecology. By Charles H. May, M. D., 
late House Surgeon to Mount Sinai Hospital, ISTew York. Second edition, edited by 
L. S. Bau, M. D., Attending Gynecologist at the Harlem Hospital, N. Y. In one 12mo. 
volume of 360 pages, with 31 illustrations 



This is a manual of gynecology in a very con- 
densed form, and the fact that a second edition 
has been called for indicates that it has met with 
a favorable reception. It is intended, the author 
tells us, to aid the student who after having care- 
fully perused larger works desires to review the 
subject, and he adds that it may be useful to the 
practitioner who wishes to refresh his memory 



Cloth, $1.75. 
rapidly but has not the time to consult larger 
works. We are much struck with the readiness 
and convenience with which one can refer to any 
subject contained in this volume. Carefully com- 
piled indexes and ample illustrations also enrich 
the work. This manual will be found to fulfil its 
purposes very satisfactorily. — The Physician and 
Surgeon. 



ASHWELL'S PRACTICAL TREATISE ON THE 
DISEASES PECULIAR TO WOMEN. Third 



American from the third and revised London 
edition. In one 8vo. vol., pp. 520. Cloth, $3.50. 



Lea Brothers & Co., Publishers, 706, 70S & 710 Sansom Street, Philadelphia. 



Obstetrics. 29 



Parvin's Science & Art of Obstetrics.— New (3d) Ed. Just Ready. 

The Science and Art of Obstetrics. By Theophiltts Parvin, M.D., 
L.L D., Professor of Obstetrics and the Diseases of Women and Children in Jefierson 
Medical College, Philadelphia. New (3d) edition In one very handsome octavo volume 
of 677 pages, with 267 engravings, and 2 colored p^tes. Cloth $4.25; leather, $5.2o 

No branch of medicine has enjoyed greater advancement during recent years than 
Obstetrics, and none is more important for the vast majority of practiti oners. The universal 
distribution of the cases, and the dependence of two lives in each, render it incumbent upon 
every physician accepting obstetric engagements to possess the most recent and authoritative 
works. The vast experience of the author and his eminent position as a teacher have led to 
the demand for successive editions of his great work, each of which has been revised to reflect 
its subject to date of issue. In the present edition nearly one-third has been rewritten, and 
additional illustrations and two colored plates enrich its abundant pictorial teachings. 

Playfair's Midwifery.— New (8th) Edition. 

A Treatise on the Science and Practice of Midwifery. By W. S. 

Playfair, M. D., F. K, C. P., Professor of Obstetric Medicine in King's College, Lon- 
don, Examiner in Midwifery in the Universities of Cambridge and London, and to the 
Eoyal College of Physicians." Sixth American, from the eighth English edition. Edited, 
with additions, by Robert P. Harris, M. D. In one handsome octavo volume of 697 
pages, with 217 engravings and 5 plates. Cloth, $4.00; leather, $5.00. 

This well-known treatise has been either a text- 
book or work of reference in most medical schools 
for the past seventeen years, and in the numerous 
editions which have appeared it has been kept 
constantly in the foremost rank of the books which 
have been written on this subject, and is a work 
which can be conscientiously recommended to the 
profession. — The Albany Med. Annals. 

This woik of Piayfair must occupy a fore- 
most place in obstetric medicine as a safe 
guide to both student and obstetrician. It holds 
a place among the ablest English speaking author- 



ities on the obstetric art— Buffalo Medical and 
Swg'cal Journal. 

The author's object has been to place in the 
hands of his readers an epitome oi the science 
and practice of midwifery, which embodies all 
recent advances, and especially to dweli on the 
practical part of the subject, so as to make his 
books a reliable guide to the doctor in the practice 
of this mo.«t important and responsible branch of 
medicine. The demand lor this eighth edition of 
the work testifies to the success with which the 
author has executed his purpose. — The Medical 
Fortnightly. 



King's Manual of Obstetrics.— New (6th) Edition. Just Ready. 

A Manual of Obstetrics. By A. F. A. King, M.D., Professor of Obsterics 
and Diseases of Women in the Medical Department of the Columbian University, Wash- 
ington, D.C., and in the University of Vermont, etc. New (6th) edition. In one 12mo. 
volume of 532 pages, with 221 illustrations. Cloth, $2.o0. 

The presentation of a subject in epitome renders a double service. It enables students 
to grasp the essentials in a manner best suited to an intelligent conception of the whole, and 
it furnishes practitioners with the most convenient means of refreshing their knowledge as 
well as with a quick reference in emergencies. Six editions of this Manual indicate that both 
classes of readers have learned to appreciate its advantages. The author possesses in 
eminent degree the art of selecting the essentials of his subject, and presenting them in clear 
language with adequate illustrations. The present edition has been thoroughly revised. 

Barnes' System o! Obstetric Medicine and Surgery. 

A System of Obstetric Medicine and Surgery, Theoretical and 
Clinical. For the Student and the Practitioner. By Eobert Barnes, M. D., Phys- 
ician to the General Lying-in Hospital, London, and Fancour t Barne-, M. D., Obstetric 
Physician to St. Thomas' Hospital, London. ' The Section on Embryology by Prof. Milnes 
Marshall. In one 8vo. volume of 872 pp., with 231 illustrations. Cloth, $5 ; leather, $6. 

Davis' Obstetrics.— Preparing. 

A Treatise on Obstetrics. For Students and Practitioners. By Edwabd 
P. Da vi?, A.M., M. D., Professor of Obstetrics and Diseases of Infancy in the Philadel- 
phia Polyclinic, Clinical Professor of Obstetrics in the Jefferson Medical College of 
Philadelphia. In one very handsome octavo volume of 500 pages, richly illustrated. 

Landis on Labor and the Lying-in Period. 

The Management of Labor, and of the Lying-in Period. 

By Henry G. Landis, A. M., M. D., Professor of Obstetrics and the Diseases of Women 
in Starling Medical College, Columbus, Ohio. In one handsome 12mo. volume of 334 
pages, with 28 illustrations. Cloth, $1.75. 

RAMSBOTHAM'S PRINCIPLES AND PRAC- I OHURCHILL ON THE PUERPERAL FEVER 
TICE OF OBSTETRIC MEDICINE AND AND OTHER DISEASES PECULIAR TO WO- 
SURGERY. In one octavo volume of 640 pages, | MEN. In one 8vo. vol. of 464 pages. Cloth, $?.50. 
with 64 full page plates and 43 woodcuts in the LEISHMAN'S SYSTEM OF MIDWIFERY, IN- 
text. Leather, 87. CLUDING THE DISEASES OF PREGNANCY 

TANNER ON PREGNANCY. Octavo, 490 pages, AND THE PUERPERAL STATE. Octavo, 
colored plates, 16 cuts. Cloth, $4.25 



Lea Brothers & Co., Publishers, 706, 708 & 710 Sansom Street Philadelphia. 



30 Dis. of Children, Obstetrics — (Cont'd), Manuals. 
Smith on Children.— Seventh Edition. 

A Treatise on the Diseases of Infancy and Childhood. By 

J. Lewis Smith, M. D., Clinical Professor of Diseases of Children in the Bellevue Hospital 
Medical College, New York. New (seventh) edition, thoroughly revised and rewritten. 
In one handsome octavo volume of 881 pages, with 51 illus. Cloth, $4.50 ; leather, $5.50. 

We have always considered Dr. Smith's book as 
one of the very best on the subject. It has always 
been practical— a field boob, theoretical where 



theory has been deduced from practical experi- 
ence. He takes his theory from the bedside and 
the pathological laboratory. The very practical 
character of this book has always appealed to us. 
It is characteristic of Dr. Smith "in all his writings 
to collect whatever recommendations are found in 
medical literature, and his search has been wide. 
One seldom fails to find here a practical suggestion 
after search in other works has been in vain. In 
the seventh edition we note a variety of changes 
in accordance with the progress of the times. It 
still stands foremost as ihe American text-book. 
The literary style could not be excelled, its advice 



is always conservative and thorough, and the 
evidence of research has long since placed its 
author in the front rank of medical teachers. — 
The American Journal of the Medical Sciences. 

In the present edition we notice that many of 
the chapters have been entirely rewritten. Full 
notice is taken of all the recent advances that 
have been made. Many diseases not previously 
treated of have received special chapters. The 
work is a very practical one. Especial care has 
been taken that the directions for treatment shall 
be particular and full. In no other work are such 
careful instructions given in the details of infant 
hygiene and the artificial feeding of infants,— 
Montreal Medical Journal. 



Herman's First Lines in Midwifery. 

First Lines in Midwifery: a Guide to Attendance on Natural 
Labor for Medical Students arid Midwives. By G-. Ernest Herman, M. B., 
F. B.C. P., Obstetric Physician to the London Hospital. In one 12mo. volume of 198 
pages, with 80 illustrations. Cloth, $1.25. See Students Series of Manuals, below. 

This is a little book, intended for the medical j will prove valuable to the beginner in midwifery 
student and the educated midwife. The work j and could be read with advantage by the majority 
is written in a plain, simple style, and is as of practitioners, old and young. — The Medical 
much as possible devoid of technical terms. It | Fortnightly. 



Owen on Surgical Diseases of Children. 

Surgical Diseases of Children. By Edmund Owen, M. B., F. K. C. S., 

Surgeon to the Children's Hospital, Great Ormond Street, London. In one 12mo. vol- 
ume of 525 pages, with 4 chromo-lithographic plates and 85 woodcuts. Cloth, $2.00. 
See Series of Clinical Manuals, below. 

Student's Series of Manuals. 

A Series of Fifteen Manuals, for the use of Students and Practitioners of Medicine and Surgery, 
written by eminent Teachers or Examiners, and issued in pocket-size 12mo. volumes of 300-540 pages, 
richly illustrated and at a low price. The following volumes are now ready: Luff's Manual of Chem- 
istry,^!; Herman's First Lines in Midwifery, $1.25; Treves' Manual of Surgery, by various writers, in 
Ihree volumes, per set, $6; Bell's Comparative Anatomy and Physiology, $2; Gould's Surgical 
Diagnosis, S2; Robertson's Physiological Physics, $2; Bruce's Materia Medica and Therapeutics (5th edi- 
tion), $1.50; Power's Human Physiology (2d edition), $1.50; Clarke and Lockwood's Diisectors' 1 Man- 
ual, $1.50 ; Ralfe's Clinical Chemistry, $1. 50; Treves' Surgical Applied Anatomy, $2; Pepfer's Surgical 
Pathology, $2; and Klein's Elements of Histology (4th edition), $1.75. The following is in press 
Pepper's Forensic Medicine. For separate no! ices see index on last page. 

Series of Clinical Manuals. 

In arranging for this Series it has been the design of the publishers to provide the profession with 
a collection of authoritative monographs on important clinical subjects in a cheap and portable form. 
The volumes contain about 550 pages and are freely illustrated by chromo-lithographs and wood- 
cuts. The following volumes are now ready: Ball on the Rectum and Anus, second edition, $2.25; 
Yeo on Food in Health and Disease, $2; Broadbent on the Pulse, $1.75; Carter & Frost's Ophthalmic 
Surgery, $2.25 ; Hutchinson on Syphilis, $2.25; Marsh on the Joints, $2; Owen on Surgical Diseases 
of Children, $2; Morris on Surgical Diseases of the Kidney, $2.25; Pick on Fractures and Disloca- 
tions, $2; Butlin on the Tongue, $150; Treves on Intestinal Obstruction, $2; and Savage on Insanity 
and Allied Neuroses, $2. The following is in preparation: Lucas on Diseases of the Urethra. For sepa- 
rate notices see index on last page. 

Hartsiiorne's Conspectus of the Medical Sciences. 

A Conspectus of the Medical Sciences ; Containing Handbooks on Anat- 
omy, Physiology, Chemistry, Materia Medica, Practice of Medicine, Surgery and Obstetrics. 
By Henry Ha'rtshorne, A. M., M. D., LL. D., lately Professor of Hygiene in- the Uni- 
versity of Pennsylvania. Second edition, thoroughly revised and greatly improved. In 
one large royal 12mo. vol. of 1028 pages, with 477 illus. Cloth, $4.25 ; leather, $5.00. 

PARRY ON EXTRA-UTERINE PREGNANCY: 
Its Clinical History, Diagnosis, Prognosis and 
Treatment. Octavo, 272 pages. Cloth, $2.50. 

CONDIE'S PRACTICAL TREATISE ON THE 
DISEASES OF CHILDREN. Sixth edition, re- 
vised and augmented. In one octavo volume of 
779 oast*"! Oiloth, $1.25 ; leather, §6.25. 

LUDLOW'S MANUAL OF EXAMINATIONS. A 
Manual of Examinations upon Anatomy, Physi- 
ology, Surgery, Practice of Medicine, Obstetrics, 
Materia Medica, Chemistry, Pharmacy and 
Therapeutics. To which is added a Medical 
Formulary. By J. L. Ludlow, M. D., Consulting 



Physician to the Philadelphia Hospital, etc. 
Third edition, thoroughly revised, and greatly 
enlarged. In one 12rno. volume of 816 pages, 
with 370 illustrations. Cloth, $3.55; leather, $3.75. 

WEST ON SOME DISORDERS OF THE NERV- 
OUS SYSTEM IN CHILDHOOD. In one small 
12mo. volume of 127 pages. Cioth, $1.00. 

WINCKEL'S COMPLETE TREATISE ON THE 
PATHOLOGY AND TREATMENT OF CHILD- 
BE!*. For Students and Practitioners. Trans- 
lated from the second German edition, by J. R. 
Chadwick, M. D. Octavo 484 pages. Cloth. $4.00. 



Lea Brothers & Co,, Publishers, 706, 708 & 710 Sansom Street, Philadelphia. 



fledical Jurisprudence, Historical, 



31 



Taylor's Medical Jurisprudence.— Twelfth Edition. 

A Manual of Medical Jurisprudence. By Alfred S. Taylor, M.D., 
Lecturer on Med. Jurisprudence and Chemistry in Guy's Hosp., London. New American 
from the 12th English edition. Thoroughly revised by Clark Bell, Esq., of the New 
York Bar. In one octavo volume of 787 pages, with 56 illus. Cloth, $4.50; leather, $5.50. 

into the criminal courts. The editor has given to 



This is a complete revision of all former Ameri- 
can and English editions of this standard book. 
This edition contain* a large amount of entirely 
new matter, many portions of the book having 
been rewritten by the editor. Many cases and 
authorities have been cited, and the citations 
brought down to the latest date. The book has 
long been a standard treatise on the subject of 
medical jurisprudence, and ha* gone through 
many editions — twelve English and eleven Ameri- 
can." Mr. Clark Bell has enlarged and improved 
what already seemed complete, by bringing his 
many citatio'ns of cases down to date to meet the 
present law; and by adding much new matter he 
has furnished the medical profession and the bar 
with a valuable book of reference, one to be relied 
upon in daily practice, and quite up to the present 
needs, owing to its exhaustive character. It 
would seem that the book is indispensable to the 
library of both physician and lawyer, and particu- 
larly the legal practitioner whose' duties take him 



two professions a reference-book to be relied upon. 
— The American Journal of the Medical Sciences. 

No library is complete without Taylor's Medical 
Jurisprudence, as its authority is accepted and un- 
questioned by the courts.— -Buffalo Medical and 
Surgical Jour nil. 

There is no other work upon the subject which 
has been so uniformly recognized or so widely 
quoted and 'bllowed by'courts in England and this 
country. This eleventh American edition is fully 
abreast with the most recent thought and knowl- 
edge. On the basis of his own researciies, of the 
investigations of scientists throughout the world, 
and of the decisions of our own courts, Mr. Bell 
has incorporated in it a wealth of practical sug- 
gestion and instructive illustration which cannot 
fail to strengthen the hold it has so long had 
upon the profession. — The Criminal Law Magazine 
and Reporter. 



By the Same Author. 
Poisons in Relation to Medical Jurisprudence and Medicine. Third 
American, from the third and revised English edition. In one large octavo volume of 788 
pages. Cloth, $5.50 ; leather, $6.50. 

Lea's Superstition and Force.— New Edition. Just Ready. 

Superstition and Force: Essays on The Wager of Law, The 
Wager of Battle, The Ordeal and Torture. By Henry Charles Lea, 
LL. D., New (4th) edition, revised and enlarged. Royal 12mo., 629 pages, ("loth, $2.75. 



Both abroad and a', home the work has been 
accepted as a standard authority, and the author 
has endeavored by a complete revision and con- 
siderable additions to render it more worthy of 
the universal favor which ha^ carried it to a 
fourth edition. The known erudition and fidelity 
of the author are guarantees that all possible origi- 
nal sources of information have been not only 



consulted but exhausted. The subject matter is 
handled in such an able and philosophic man- 
ner that to read and study it is a step toward 
liberal education. It is a comfort to read a book 
that is so thorough, well conceived and well done. 
We should like to see it made a text-book in our 
law schools and prescribed course for admission 
to the bar. — Legal Intelligencer. 



By the same Author. 
Chapters from the Religious History of Spain.— In one 12mo. volume 

of 522 pages. Cloth $2.50. 



The width, depth and thoroughness of research 
which have earned Dr. Lea a high European place 
as the ablest historian the Inquisition has yet 
found are here applied to some side-issues of that 
great subject. We have only to say of this volume 



that it worthily complements the author's earlier 
studies in ecclesiastical history. His extensive 
and minute learning, much of it from inedited 
manuscripts in Mexico, appears'on every page. — 
London Antiquary. 



In one 8vo. volume of 219 



By the same Author. 
The Formulary of the Papal Penitentiary. 
pages, with a frontispiece. Cloth, $2.50. 

By the Same Author. 
Studies in Church History. The Rise of the Temporal Power— Ben- 
efit of Clergy— Excommunication— The Early Church and Slavery. Sec- 
ond and revised edition. In one royal octavo volume of 605 pages. Cloth, $2.50. 



The author is preeminently a scholar; he takes 
up every topic allied with the leading theme and 
traces it cut to the minutest detail with a wealth 
of knowledge and impartiality of treatment that 
compel admiration. The amount of information 
compressed into the book is extraordinary, and 
the profuse citation of authorities and references 



makes the work particularly valuabletothe student 
who desires an exhaustive review from original 
sources. In no other single volume is the develop- 
ment of the primitive church traced with so much 
clearness and with so definite a perception of 
complex or conflicting forces.— Boston Traveller. 



By the Same Author. 
An Historical Sketch of Sacerdotal Celibacy in the Christian 
Church. Second edition^ enlarged. In one octavo volume of 685 pages. Cloth, $4.50. 



This subject has recently been treated with very 
great learning and with admirable impartiality by 
an American author, Mr. Henrv G. Lea ; in his His- 
tory of Saceraotai celibacy, which is certainly one 
of the most valuable works that America has pro- 
duced. Since the great history of Dean Milman, 
I know no work in English which has thrown 



more light on the moral condition of the Middle 
Ages, and none which is more fitted to dispel the 
gross illusions concerning that period which posi- 
tive writers and writers of a certain ecclesiastical 
school have conspired to sustain. — Lecky's History 
of European Morals, Chap. V. 



By the Same Author. 
A History of Auricular Confession and Indulgences in the Latin 
Church. In three octavo volumes of 500 pages. In press. 

Lea Brothers & Co., Publishers, 706, 708 & 710 Sansom Street, Philadelphia. 



Index to Catalogue of Medical Publications 

— or — 

Lea Brothers & Co., 



706, 708 & 710 Sansom Street, PHILADELPHIA. 



Abbott's Bacteriology .... 19 

Allen's inatomy 6 

American Journal of the Med- 
ical Sciences 2 

American Systems of Gynecol- 
ogy and Obstetrics . ... 27 
American System of Practical 

Medicine 14 

American System of Dentistry 24 
American Text-Books of Dent- 
istry , . . 24 

A shhurst's Surgery 20 

Asbwell on Diseases of Women 28 

Attfield's Chemistry 9 

Ball on the Rectum and Anus 21, 30 
Barnes' System of Obstetric 

Medicine and Surgery ... 29 

Bartholow on Cholera .... 16 

Bartholow on Electricity . . 16 

Basham on Renal Diseases . . 23 
Bell's Comparative Anatomy 

and Physiology 7, 30 

Bellamy's Surgical Anatomy . 6 

Berry on the Eye 23 

Billings' National Medical Dic- 
tionary 4 

Black on the Urine 24 

Blandford on Insanity .... 17 

Bloxam's Chemistry 9 

Broadbent on the Pulse . . 15, 30 

Browne on Koch's Remedy . . 17 
Browne on the Throat, Nose 

and Ear 17 

Brace's Materia Medica and 

Therapeutics 13, 30 

Brunton's Materia Medica and 

Therapeutics 13 

Bryant's Practice of Surgery . 20 
Bumstead and Taylor on Vene- 
real Diseases See Taylor . . 25 

Burnett on the Ear 24 

Butlin on the Tongue . . . 20, 30 
Carpenter on the Use and Abuse 

of Alcohol 7 

Carpenter's Human Physiology 7 
Carter & Frost's Ophthalmic 
Surgery ........ 23, 30 

Caspari's Pharmacy ... 10 

Chambers on Diet and Regimen 16 

Chapman's Human Physiology 8 
Charles' Physiological and 

Pathological ( 'here istry . . . 10 
Cheyne on "Wounds, Ulcers 

and Abcessess 21 

Churchill on Puerperal Fever . 29 
Clarke and Lcckwood's Dissec- 
tors' Manual 6, 30 

Cleland's Dissector 6 

Clouston on Insanity .... 17 

Clowes' Practical Chemistry . 8 

Coats' Pathology ...... 19 

Cohen's Applied Therapeutics 12 

Coleman's Dental Surgery . . 24 

Condie on Diseases of Children 30 

Cornil on Syphilis 25 

Culver & Hayden on Venereal 

Diseases 25 

Dalton on the Circulation . . 7 

Dalton's Human Physiology . 8 

Davenport on Dis of Women . 28 

Davis' Clinical Lectures . . . 14 

Davis' Obstetrics 29 

Dennis' System of Surgery . . 22 

Dercum on Nervous Diseases . 18 

Dispensatory. The National . . 11 

Draper's Medical Physics ... 7 

Druitt's Modern Surgery . . 20 

Duane's Medical Dictionary . . 3 

Duncan on Diseases of Women 27 

Dungllson's Medical Dictionary 4 
Edes' Materia Medica and 

Therapeutics 12 

Edis on Diseases of Women . 27 

Ellis' Anatomv 7 

E mm et's Gynaecology .... 27 

Erichsen's Surgery 20 

Farquharson's Therapeutics 

and Materia Medica ... 13 
Field's Manual of Diseases of 

the Ear 24 

Flint on Auscultation and Per- 
cussion 15 

Flint on Phthisis 13 

Flint on Respiratory Organs . 14 

Flint on the Heart 13 

Flint's Essays 13 

Flint's Practice of Medicine . . 13 
Folsom's Laws of U. S. on Cus- 
tody of Insane 17 

Foster's Physiology 8 

Fothergill's Handbook of 

Treatment 15 

Fownes' Elementary Chemistry 9 
Frankland and Japp's Inor- 
ganic Chemistry 8 



[ Fuller on the Lungs and Air 



17 

Fuller on Male Sexual Disorders 25 

Gant's Student's Surgery . . 20 

Gibbes' Practical Pathology . 19 
Gould's Surgical Diagnosis . 20, 30 
Gray on Nervous and Mental 

Diseases 18 

Gray's Anatomy 5 

Greene's Medical Chemistry . 9 
Green's Pathology and Morbid 

Anatomy 19 

Gross on Impotence and Sterility 25 
Gross on Urinary Organs ... 25 
Habershon on the Abdomen . 14 
Hamilton onFractures and Dis- 
locations 22 

Hamilton on Nervous Diseases 18 

Hardaway on the Skin ... 25 

Hare's Practical Therapeutics . 12 
Hare's System of Practical 

Therapeutics 12 

Hartshorne's Anatomy and 

Physiology . . . , . . . 6 
Hartshorne's Conspectus of the 

Medical Sciences . , . . . 30 
Hartshorne's Essentials of 

Medicine . 13 

Hayem's Physical and Natural 

Therapeutics . ..... 16 

Herman's Midwifery .... 30 

Hermann's Experimental Phar- 
macology 13 

Herrick's Diagnosis 16 

Hill on Syphilis 25 

Hillier's Handbook of Skin 

Diseases 26 

Hirst & Piersol on Human 

Monstrosities 6 

Hoblyn's Medical Dictionary . 5 

Hodge on Women .27 

Hoffmann and Power's Chem- 
ical Analysis ....... 10 

Holden's Landmarks .... 6 

Holland's Medical Notes and 

Reflections . . , 14 

Holmes' Surgery ...... 20 

Holmes' Svstem of Surgery . . 20 
Horner's Anatomy and Histology 6 

Hudson on Fever 13 

Hutchinson on Syphilis . . 25, 30 

Hyde on the Skin 26 

Jackson on the Skin . . . 26 

Jamieson on the Skin .... 26 

Jones on Nervous Disorders . 17 
Juler'3 Ophthalmic Science and 

Practir-e 23 

King's Manual of Obstetrics . . 29 

Klein's Histology 18,30 

Landis on Labor 29 

La Roche on Pneumonia, Mala- 

lia. eu:. 17 

La Roche on Yellow Fever . . 13 
Laurence and Moon's Ophthal- 
mic Sur«er\ 23 

Lawson on the Eye 23 

Lea's Auricular Confession and 

Indulgences 31 

Lea's Chapters from Religious 

History of Spain 31 

Lea's Formulary of the Papal 

Penitentiary 31 

Lea's Sacerdotal Celibacy ... 31 

Lea's Studies in Church History 31 

Lea's Superstition and Force . 31 

Lee on Syphilis 25 

Lehmann's Chemical Physiology 7 
Leishman's Midwifery .... 29 
Lucas on the Urethra .... 30 
.Ludlow's Manual of Examina- 
tions 30 

Luff's Manual of Chemistry . 9, 30 

Lyman's Practice of Medicine 14 

Lyons on Fe\ er 13 

Maisch's Organic Materia Medica 12 

Mackenzie on Nose and Throat 17 
Marsh on the Joints ... 20, 30 

May on Diseases of Women . . 28 

Medical News 1 

Medical News Physicians' Ledger 2 

Medical News Visiting List . . 2 

i Miller's Practice of Surgery . . 20 

' Miller's Principles of Surgery 20 

Mitchell on Nerve Injuries . 18 
Morris on the Kidney ... 23, 30 

Morris on the Skin 26 

Musser's Medical Diagnosis . , 15 
National Dispensatory . . .11 
National Medical Dictionary . 4 
Nettleship on the Evp . 23 
Norris and Oliver on the Eye . 23 
Owen on Diseases of Children . 30 
Parry on Extra-Uterine Preg- 
nancy 30 

Parvin's Obstetrics 29 

Pavy on Digestive Disorders . 16 

Payne's General Pathology . . 19 



I Pepper's Forensic Medicine . 
1 Pepper's Surgical Pathology 18, 
i Pepper's System of Medicine . 
1 Pick on Fractures and Disloca- 

I tions 21, 

j Pirrie's System of Surgery 

! Playfair on Nerve Prostration 

! and Hysteria 

Playfair's Midwifery 

Politzer on the Ear * . . . . 

Power's Human Physiology . 7, 

Purdy on Bright's Disease and 

Allied Affections 

! Pye-Smith on the Skin . . . 

i Quiz Series 

1 Ralfe's Clinical Chemistry . 10, 

Rarnsbotham on Parturition . 

Reichtrt's Physiology .... 

Remsen's Theoretical Chemistry 

Reynolds' System of Medicine . 

Richardson's Preventive Med. 

Roberts on Urinary Diseases 
; Roberts' Compend of Anatomy 

Roberts' Surgery 

Robertson's Physiological Phys- 
| ics 7, 

Ross on Nervous Diseases . . 

Savage on Insanity, including 
Hysteria 17, 

Schafer's Histology 

Schofield's Physiology .... 

Schreiber on Massage .... 

Seiler on the Throat, Nose and 
Naso- Pharynx 

Senn's Surgical Bacteriology . 

Series of Clinical Manuals . . 

Simon's Manual of Chemistry 

Slade on Diphtheria 

Smith (Edw.) on Consumption 

Smith (J. Lewis) on Children . 

Smith's Operative Surgery . . 

Stille on Cholera 

Stilie & Maisch's National Dis- 
'1 pensatory 

Stillg's Therapeutics and Mate- 
ria Medica 

Stimson on Fractures and Dis- 
locations . ....... 

Stimson's Operative Surgery . 

Students' Quiz Series ... 

Students' Series of Manuals . . 

Sturges' Clinical Medicine . . 

Sutton on the Ovaries and Fal- 
lopian Tubes 

Sutton on Tumors 

Tait's Diseases of Women and 
Abdominal Surgery .... 

Tanner on Signs and Diseases 
of Pregnancy 

Tanner's Manual of Clinical 
Medicine 

Taylor's Atlas of Venereal and 
Skin Dieases 

Taylor's Index of Medicine . . 

Taylor on Poisons 

Taylor on Venereal Diseases 

Taylor's Medical Jurisprudence 

Thomas & Munde on Women . 

Thompson on Stricture .... 

Thompson on Urinary Organs . 

Todd on Acute Diseases . . . 

Treves' Manual of Surgery . 21, 

Treves on Intestinal Obstruc- 
tion 21, 

Treves' Operative Surgery . . 

Treves' Student's Handbook of 
Surgical Operations .... 

Treves' Surgical Applied Anat- 
omy 6, 

Tuke on the Influence of the 
Mind on the Body 

Vaughan&Novy on Ptomaines 
and Leucomaines 

Visiting List, The Medical News 

Walshe on the Heart 

Watson's Practice of Physic . . 

Wells on the Eye 

West on Diseases of Women . 

West on Nervous Disorders in 

! Childhood 

j Wharton's Minor Surgery and 
Bandaging 

Whitla's Dictionary of Treat- 
ment . 

Williams on Consumption . . 

Wilson's Handbook of Cutane- 
j ous Medicine 

Wilson's Human Anatomy . . 

Winckel on Pathology and 
Treatment of t'hi'dbed . . . 

Wohler's Organic Chemistry . 

Year-Books of Treatment for 
'8fi, '87. '91,'S2,'93,'9o 

Yeo's Medical Treatment . . . 

Yeo on Food in Health and 
Disease 16, 

Young's Orthopedic Surgery . 



